Provider Demographics
NPI:1477735132
Name:EYELAND, P.C.
Entity Type:Organization
Organization Name:EYELAND, P.C.
Other - Org Name:EAGLE EYES VISION CENTER SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:719-591-8889
Mailing Address - Street 1:2750 S ACADEMY BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916-2852
Mailing Address - Country:US
Mailing Address - Phone:719-591-8889
Mailing Address - Fax:
Practice Address - Street 1:2750 S ACADEMY BLVD STE 130
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80916-2852
Practice Address - Country:US
Practice Address - Phone:719-591-8889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO68123876Medicaid