Provider Demographics
NPI:1184747230
Name:MONTE VISTA EYE CARE CENTER INC.
Entity type:Organization
Organization Name:MONTE VISTA EYE CARE CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:HEERSINK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:719-852-3412
Mailing Address - Street 1:101 CHICO CT
Mailing Address - Street 2:
Mailing Address - City:MONTE VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81144-1067
Mailing Address - Country:US
Mailing Address - Phone:719-852-3412
Mailing Address - Fax:719-852-3345
Practice Address - Street 1:101 CHICO CT
Practice Address - Street 2:
Practice Address - City:MONTE VISTA
Practice Address - State:CO
Practice Address - Zip Code:81144-1067
Practice Address - Country:US
Practice Address - Phone:719-852-3412
Practice Address - Fax:719-852-3345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO990152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08009904Medicaid
CO08009904Medicaid
C76333Medicare ID - Type Unspecified