Provider Demographics
NPI:1386188076
Name:L.L. DOUGLASS, OD, PLLC
Entity Type:Organization
Organization Name:L.L. DOUGLASS, OD, PLLC
Other - Org Name:DOUGLASS VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:806-662-6812
Mailing Address - Street 1:9601 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80229-2155
Mailing Address - Country:US
Mailing Address - Phone:303-453-4972
Mailing Address - Fax:
Practice Address - Street 1:9601 GRANT ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-2155
Practice Address - Country:US
Practice Address - Phone:303-453-4972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003268152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX354129401Medicaid
TX354129401Medicaid