Provider Demographics
NPI:1588800817
Name:COLLEEN PERSONETT, OD, LLC
Entity Type:Organization
Organization Name:COLLEEN PERSONETT, OD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERSONETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:907-479-4700
Mailing Address - Street 1:570 RIVERSTONE WAY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-2939
Mailing Address - Country:US
Mailing Address - Phone:907-479-4700
Mailing Address - Fax:
Practice Address - Street 1:570 RIVERSTONE WAY
Practice Address - Street 2:SUITE 3
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-2939
Practice Address - Country:US
Practice Address - Phone:907-479-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKA192152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKU95650Medicare UPIN
AK1295894103Medicare NSC