Provider Demographics
NPI:1306019047
Name:DALE G. LERVICK, O.D., P.C.
Entity Type:Organization
Organization Name:DALE G. LERVICK, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:LERVICK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:303-233-7575
Mailing Address - Street 1:7586 W JEWELL AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80232-6890
Mailing Address - Country:US
Mailing Address - Phone:303-233-7575
Mailing Address - Fax:303-233-4740
Practice Address - Street 1:7586 W JEWELL AVE
Practice Address - Street 2:STE 104
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80232-6890
Practice Address - Country:US
Practice Address - Phone:303-233-7575
Practice Address - Fax:303-233-4740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9977799152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08007775Medicaid
CO0406690001Medicare NSC
CO08007775Medicaid
CO77013Medicare PIN