Provider Demographics
NPI:1992868194
Name:CORTEZ VISION PC
Entity Type:Organization
Organization Name:CORTEZ VISION PC
Other - Org Name:CORTEZ VISION CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-565-2020
Mailing Address - Street 1:PO BOX 820
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-0820
Mailing Address - Country:US
Mailing Address - Phone:970-565-2020
Mailing Address - Fax:970-565-3632
Practice Address - Street 1:2423 E MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-4269
Practice Address - Country:US
Practice Address - Phone:970-565-2020
Practice Address - Fax:970-565-3632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2046152W00000X
CO904152W00000X
CO2803152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO06979238Medicaid
CO0779800001Medicare NSC
COCF6703Medicare PIN