Provider Demographics
NPI:1679744841
Name:SOUTHERN COLORADO EYE CARE ASSOCIATES PC
Entity Type:Organization
Organization Name:SOUTHERN COLORADO EYE CARE ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:COZZETTA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:719-542-3555
Mailing Address - Street 1:1620 FORTINO BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1856
Mailing Address - Country:US
Mailing Address - Phone:719-542-3555
Mailing Address - Fax:719-542-0776
Practice Address - Street 1:1620 FORTINO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1856
Practice Address - Country:US
Practice Address - Phone:719-542-3555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1043277973OtherPROVIDER NPI
CO08013476Medicaid
CO0414180001Medicare NSC
327487Medicare UPIN
CO41603Medicare PIN