Provider Demographics
NPI:1376718429
Name:BLECHACZ, MIKE
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:BLECHACZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:959 S MILLER ST
Mailing Address - Street 2:#202
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-3927
Mailing Address - Country:US
Mailing Address - Phone:303-716-5831
Mailing Address - Fax:
Practice Address - Street 1:959 S MILLER ST
Practice Address - Street 2:#202
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226-3927
Practice Address - Country:US
Practice Address - Phone:303-716-5831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2527152W00000X
WI2701152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU72329Medicare UPIN