Provider Demographics
NPI:1346886587
Name:TABLE MOUNTAIN VISION CENTER 2020, LLC
Entity Type:Organization
Organization Name:TABLE MOUNTAIN VISION CENTER 2020, LLC
Other - Org Name:TABLE MOUNTAIN VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:303-271-1400
Mailing Address - Street 1:1409 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-1917
Mailing Address - Country:US
Mailing Address - Phone:303-271-1400
Mailing Address - Fax:
Practice Address - Street 1:1409 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401-1917
Practice Address - Country:US
Practice Address - Phone:303-271-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-22
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty