Provider Demographics
NPI:1477661221
Name:ASPEN EYEWEAR
Entity Type:Organization
Organization Name:ASPEN EYEWEAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:EBNER
Authorized Official - Suffix:
Authorized Official - Credentials:ABO
Authorized Official - Phone:303-447-0210
Mailing Address - Street 1:2525 ARAPAHOE AVE UNIT E23
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-6726
Mailing Address - Country:US
Mailing Address - Phone:303-447-0210
Mailing Address - Fax:
Practice Address - Street 1:2525 ARAPAHOE AVE
Practice Address - Street 2:E-23
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-6720
Practice Address - Country:US
Practice Address - Phone:303-447-0210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10-56711-0000332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0743970001Medicare ID - Type Unspecified