Provider Demographics
NPI:1568752293
Name:PETERSON FAMILY EYECARE
Entity Type:Organization
Organization Name:PETERSON FAMILY EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:719-599-9393
Mailing Address - Street 1:6665 DELMONICO DR
Mailing Address - Street 2:STE. A
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-6801
Mailing Address - Country:US
Mailing Address - Phone:719-599-9393
Mailing Address - Fax:
Practice Address - Street 1:6665 DELMONICO DR
Practice Address - Street 2:STE. A
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-6801
Practice Address - Country:US
Practice Address - Phone:719-599-9393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2804152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOAAA0638Medicare PIN