Provider Demographics
NPI:1942407341
Name:CHERRY CREEK OPTICAL
Entity Type:Organization
Organization Name:CHERRY CREEK OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:T
Authorized Official - Last Name:ROE
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:303-758-5477
Mailing Address - Street 1:4999 E KENTUCKY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80246-3901
Mailing Address - Country:US
Mailing Address - Phone:303-691-2233
Mailing Address - Fax:
Practice Address - Street 1:4999 E KENTUCKY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80246-3901
Practice Address - Country:US
Practice Address - Phone:303-691-2233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21624440000332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0696760001Medicare NSC