Provider Demographics
NPI:1932477627
Name:PINE CREEK VISION CLINIC, P.C.
Entity Type:Organization
Organization Name:PINE CREEK VISION CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:719-651-4014
Mailing Address - Street 1:9475-A BRIAR VILLAGE PT
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7902
Mailing Address - Country:US
Mailing Address - Phone:719-594-2020
Mailing Address - Fax:719-694-8562
Practice Address - Street 1:9475-A BRIAR VILLAGE PT
Practice Address - Street 2:SUITE 200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7902
Practice Address - Country:US
Practice Address - Phone:719-594-2020
Practice Address - Fax:719-694-8562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-08
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1380152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODU0051OtherRAILROAD MEDICARE PTAN
COCOAAA3672Medicare PIN
CODU0051OtherRAILROAD MEDICARE PTAN