Provider Demographics
NPI:1184766438
Name:EYE SURGERY CENTER OPTICAL
Entity type:Organization
Organization Name:EYE SURGERY CENTER OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:SELF
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:303-426-8812
Mailing Address - Street 1:8402 CLAY ST
Mailing Address - Street 2:STE.4
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80031-3847
Mailing Address - Country:US
Mailing Address - Phone:303-426-8812
Mailing Address - Fax:303-657-5597
Practice Address - Street 1:8402 CLAY ST
Practice Address - Street 2:STE.4
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80031-3847
Practice Address - Country:US
Practice Address - Phone:303-426-8812
Practice Address - Fax:303-657-5597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20828332H00000X
CO332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4128380001Medicare NSC