Provider Demographics
NPI:1588629257
Name:SPIVACK VISION CLINIC PC
Entity Type:Organization
Organization Name:SPIVACK VISION CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-740-2414
Mailing Address - Street 1:6881 S YOSEMITE ST
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-1406
Mailing Address - Country:US
Mailing Address - Phone:303-740-9310
Mailing Address - Fax:303-740-5494
Practice Address - Street 1:6881 S YOSEMITE ST
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-1406
Practice Address - Country:US
Practice Address - Phone:303-740-9310
Practice Address - Fax:303-740-5494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COSPA2908OtherANTHEM BC/BS
COSPA2908OtherANTHEM BC/BS