Provider Demographics
NPI:1609387703
Name:BLUE RIVER VISION PLLC
Entity Type:Organization
Organization Name:BLUE RIVER VISION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HEGEWALD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-368-6539
Mailing Address - Street 1:P.O. BOX 402
Mailing Address - Street 2:PMB 310
Mailing Address - City:DILLON
Mailing Address - State:CO
Mailing Address - Zip Code:80435-0402
Mailing Address - Country:US
Mailing Address - Phone:970-368-6539
Mailing Address - Fax:970-368-6539
Practice Address - Street 1:358 BLUE RIVER PKWY
Practice Address - Street 2:SUITE D
Practice Address - City:SILVERTHORNE
Practice Address - State:CO
Practice Address - Zip Code:80498
Practice Address - Country:US
Practice Address - Phone:303-503-6397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-16
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2671152W00000X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty