Provider Demographics
NPI:1790996379
Name:FOOTHILLS VISION CENTER, PC
Entity Type:Organization
Organization Name:FOOTHILLS VISION CENTER, PC
Other - Org Name:FOOTHILLS VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KRAJEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:303-986-5565
Mailing Address - Street 1:12810 W ALAMEDA PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-3116
Mailing Address - Country:US
Mailing Address - Phone:303-986-5565
Mailing Address - Fax:303-984-2111
Practice Address - Street 1:12810 W ALAMEDA PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-3116
Practice Address - Country:US
Practice Address - Phone:303-986-5565
Practice Address - Fax:303-984-2111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2107152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC490838Medicare PIN
CO0608410001Medicare NSC