Provider Demographics
NPI:1508383126
Name:ABBA DRY EYE & ALLERGY CLINIC, P.C.
Entity Type:Organization
Organization Name:ABBA DRY EYE & ALLERGY CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WINTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-424-4497
Mailing Address - Street 1:1130 LAKE PLAZA DR STE 145
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3595
Mailing Address - Country:US
Mailing Address - Phone:719-630-8200
Mailing Address - Fax:719-630-8201
Practice Address - Street 1:4465 NORTHPARK DR STE 206
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-4238
Practice Address - Country:US
Practice Address - Phone:719-424-4496
Practice Address - Fax:719-301-1518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPENDINGMedicaid