Provider Demographics
NPI:1801023296
Name:C. JACK ROFFIS OD, PC
Entity Type:Organization
Organization Name:C. JACK ROFFIS OD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:C. JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROFFIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:303-447-8470
Mailing Address - Street 1:1933 28TH ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1100
Mailing Address - Country:US
Mailing Address - Phone:303-447-8470
Mailing Address - Fax:303-443-9555
Practice Address - Street 1:1933 28TH ST
Practice Address - Street 2:SUITE 206
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1100
Practice Address - Country:US
Practice Address - Phone:303-447-8470
Practice Address - Fax:303-443-9555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-12
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1277152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC41663Medicare UPIN
COU31785Medicare UPIN