Provider Demographics
NPI:1265623508
Name:VISION EYELAND SUPER OPTICAL LLC
Entity type:Organization
Organization Name:VISION EYELAND SUPER OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TORGERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-493-6360
Mailing Address - Street 1:1820 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-1423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1820 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1423
Practice Address - Country:US
Practice Address - Phone:970-493-6360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01431072Medicaid
CO5235440001Medicare NSC
CO550858Medicare PIN