Provider Demographics
NPI:1407050420
Name:OMNI OPTOMETRIC ASSOCIATES, LLC
Entity Type:Organization
Organization Name:OMNI OPTOMETRIC ASSOCIATES, LLC
Other - Org Name:LAKE COUNTY VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:PROUTY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:720-252-3802
Mailing Address - Street 1:1110 BLACK SADDLE ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:CO
Mailing Address - Zip Code:80107-8528
Mailing Address - Country:US
Mailing Address - Phone:720-252-3802
Mailing Address - Fax:719-486-2584
Practice Address - Street 1:711 HARRISON AVE UNIT H
Practice Address - Street 2:
Practice Address - City:LEADVILLE
Practice Address - State:CO
Practice Address - Zip Code:80461-3571
Practice Address - Country:US
Practice Address - Phone:719-486-2505
Practice Address - Fax:719-486-2584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty