Provider Demographics
NPI:1295435881
Name:CHILDREN'S OPTICAL OF NORTHERN COLORADO LLC
Entity type:Organization
Organization Name:CHILDREN'S OPTICAL OF NORTHERN COLORADO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-214-8175
Mailing Address - Street 1:2121 E HARMONY RD UNIT 350A
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3404
Mailing Address - Country:US
Mailing Address - Phone:970-214-8175
Mailing Address - Fax:970-788-7376
Practice Address - Street 1:2121 E HARMONY RD UNIT 350A
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3404
Practice Address - Country:US
Practice Address - Phone:970-214-8175
Practice Address - Fax:970-788-7376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1053572438Medicaid
CO1255091716Medicaid