Provider Demographics
NPI:1649205113
Name:ARCHULETA EYECARE ASSOCIATES, LLC
Entity Type:Organization
Organization Name:ARCHULETA EYECARE ASSOCIATES, LLC
Other - Org Name:MOUNTIAN EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ZISSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-713-4347
Mailing Address - Street 1:190 TALISMAN DR UNIT B4
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-9171
Mailing Address - Country:US
Mailing Address - Phone:505-263-4695
Mailing Address - Fax:
Practice Address - Street 1:190 TALISMAN DR UNIT B4
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-9171
Practice Address - Country:US
Practice Address - Phone:970-731-4347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2532152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO5779510001Medicare NSC