Provider Demographics
NPI:1376612143
Name:EATON VISION CLINIC LLC
Entity Type:Organization
Organization Name:EATON VISION CLINIC LLC
Other - Org Name:EATON VISION CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:STURM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-454-3387
Mailing Address - Street 1:215 ELM AVE
Mailing Address - Street 2:
Mailing Address - City:EATON
Mailing Address - State:CO
Mailing Address - Zip Code:80615-3428
Mailing Address - Country:US
Mailing Address - Phone:970-454-3387
Mailing Address - Fax:970-454-3380
Practice Address - Street 1:215 ELM AVE
Practice Address - Street 2:
Practice Address - City:EATON
Practice Address - State:CO
Practice Address - Zip Code:80615-3428
Practice Address - Country:US
Practice Address - Phone:970-454-3387
Practice Address - Fax:970-454-3380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT 1014152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO6617000001Medicare NSC
COCOA105254Medicare PIN
CODS6882Medicare PIN