Provider Demographics
NPI:1679634471
Name:ORCHARD EYE CENTER PC
Entity Type:Organization
Organization Name:ORCHARD EYE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER FRONT OFF SUPER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROUTH
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:970-243-8697
Mailing Address - Street 1:2403 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8130
Mailing Address - Country:US
Mailing Address - Phone:970-243-8697
Mailing Address - Fax:970-243-8698
Practice Address - Street 1:2403 N 12TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8130
Practice Address - Country:US
Practice Address - Phone:970-243-8697
Practice Address - Fax:970-243-8698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2476152W00000X
CO36956174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO917805OtherSECURE HORIZON
CO634810OtherBCBS INDIVIDUAL
COGEG9008OtherBCBS GROUP
CO01369560Medicaid
CO634810OtherBCBS INDIVIDUAL
COGEG9008OtherBCBS GROUP
COV06166Medicare UPIN
COG9048Medicare ID - Type Unspecified
CO1800341911Medicare ID - Type UnspecifiedRR MEDICARE
CO=========007OtherROCKY MNT HEALTH PLANS
CO634810OtherBCBS INDIVIDUAL