Provider Demographics
NPI:1205077799
Name:EYE CENTER OF THE ROCKIES PC
Entity type:Organization
Organization Name:EYE CENTER OF THE ROCKIES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:EHRLICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-926-7773
Mailing Address - Street 1:0377 SYLVAN LAKE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631
Mailing Address - Country:US
Mailing Address - Phone:970-926-7773
Mailing Address - Fax:
Practice Address - Street 1:4236 PORTOFINO DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-4154
Practice Address - Country:US
Practice Address - Phone:970-926-7773
Practice Address - Fax:970-945-9793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-13
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43386174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOB4608Medicare PIN