Provider Demographics
NPI:1760616148
Name:TOM'S SPORTIQUE EYEWEAR
Entity Type:Organization
Organization Name:TOM'S SPORTIQUE EYEWEAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BUELL
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:303-442-2010
Mailing Address - Street 1:3121 28TH ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1315
Mailing Address - Country:US
Mailing Address - Phone:303-442-2010
Mailing Address - Fax:303-442-2010
Practice Address - Street 1:3121 28TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1315
Practice Address - Country:US
Practice Address - Phone:303-442-2010
Practice Address - Fax:303-442-2010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4320510001Medicare PIN