Provider Demographics
NPI:1568589505
Name:WM. REX ELAND, O.D., P.C.
Entity Type:Organization
Organization Name:WM. REX ELAND, O.D., P.C.
Other - Org Name:BERTHOUD VISION FOR LIFE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:REX
Authorized Official - Last Name:ELAND
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-532-5605
Mailing Address - Street 1:1211 LAKE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:BERTHOUD
Mailing Address - State:CO
Mailing Address - Zip Code:80513-9381
Mailing Address - Country:US
Mailing Address - Phone:970-532-5605
Mailing Address - Fax:970-532-5607
Practice Address - Street 1:1211 LAKE AVE STE 102
Practice Address - Street 2:
Practice Address - City:BERTHOUD
Practice Address - State:CO
Practice Address - Zip Code:80513-9381
Practice Address - Country:US
Practice Address - Phone:970-532-5605
Practice Address - Fax:970-532-5607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT-1026152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO63821371Medicaid
CO63821371Medicaid
DCC802171Medicare PIN