Provider Demographics
NPI:1710040241
Name:EKLUND OPTOMETRIC GROUP, LLC
Entity Type:Organization
Organization Name:EKLUND OPTOMETRIC GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:EKLUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-568-7161
Mailing Address - Street 1:PO BOX 350
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:CO
Mailing Address - Zip Code:80549-0350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 DELL RANGE BLVD
Practice Address - Street 2:SUITE 69B
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4801
Practice Address - Country:US
Practice Address - Phone:307-778-0700
Practice Address - Fax:307-632-6342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY10461Medicare ID - Type Unspecified