Provider Demographics
NPI:1679272926
Name:LONGMONT FAMILY EYE DOCTORS PLLC
Entity Type:Organization
Organization Name:LONGMONT FAMILY EYE DOCTORS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITMIRE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:401-743-4509
Mailing Address - Street 1:12517 DEXTER WAY
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80241-3065
Mailing Address - Country:US
Mailing Address - Phone:401-743-4509
Mailing Address - Fax:
Practice Address - Street 1:205 E KEN PRATT BLVD
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-8500
Practice Address - Country:US
Practice Address - Phone:401-743-4509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO26283573Medicaid