Provider Demographics
NPI:1437346343
Name:BOULDER VISION ASSOCIATES, P.C., INC.
Entity Type:Organization
Organization Name:BOULDER VISION ASSOCIATES, P.C., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:PADDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:303-530-2020
Mailing Address - Street 1:5305 SPINE RD STE B
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3331
Mailing Address - Country:US
Mailing Address - Phone:303-530-2020
Mailing Address - Fax:
Practice Address - Street 1:5305 SPINE RD STE B
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3331
Practice Address - Country:US
Practice Address - Phone:303-530-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2534152W00000X
CO1436152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC522349Medicare PIN