Provider Demographics
NPI:1508903220
Name:CENTENNIAL EYE ASSOCIATES PLLC
Entity Type:Organization
Organization Name:CENTENNIAL EYE ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BURRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:303-699-3107
Mailing Address - Street 1:14000 E ARAPAHOE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-4043
Mailing Address - Country:US
Mailing Address - Phone:303-699-3107
Mailing Address - Fax:303-699-3170
Practice Address - Street 1:14000 E ARAPAHOE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-4043
Practice Address - Country:US
Practice Address - Phone:303-699-3107
Practice Address - Fax:303-699-3170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1408152W00000X
CO33900207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1222570001Medicare NSC
COCN3108Medicare PIN