Provider Demographics
NPI:1518939834
Name:ALPINE EYE CLINIC OPTICAL, LLC
Entity Type:Organization
Organization Name:ALPINE EYE CLINIC OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-565-8809
Mailing Address - Street 1:2423 E MAIN ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-4269
Mailing Address - Country:US
Mailing Address - Phone:970-565-8809
Mailing Address - Fax:970-565-8881
Practice Address - Street 1:2423 E MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-4269
Practice Address - Country:US
Practice Address - Phone:970-565-8809
Practice Address - Fax:970-565-8881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28-1598318156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO5270990001Medicare ID - Type Unspecified