Provider Demographics
NPI:1346498458
Name:VAIL VISION PC
Entity Type:Organization
Organization Name:VAIL VISION PC
Other - Org Name:VAIL VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:PAGE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-926-8474
Mailing Address - Street 1:PO BOX 544
Mailing Address - Street 2:1140 EDWARDS VILLAGE BLVD B206
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-0544
Mailing Address - Country:US
Mailing Address - Phone:970-926-8474
Mailing Address - Fax:970-926-3634
Practice Address - Street 1:1140 EDWARDS VILLAGE BLVD B206
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632
Practice Address - Country:US
Practice Address - Phone:970-926-8484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO859152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOB4187Medicare PIN