MEDICARE: CCC OPTICAL PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1409	CO

General Provider Information

NPI Number	:	1194713057
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CCC OPTICAL PC

Provider Business Mailing Address
First Line	:	2509 MAIN ST
Second Line	:
City	:	ALAMOSA
State	:	CO
Zip	:	81101-2239
Country	:	US
Telephone Number	:	719-589-9066
Fax Number	:	719-589-4079

Provider Business Practice Location Address
First Line	:	190 TALISMAN DR
Second Line	:	SUITE B4
City	:	PAGOSA SPRINGS
State	:	CO
Zip	:	81147-9171
Country	:	US
Telephone Number	:	970-731-4347
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR/OPTOMETRIST
Name	:	DR. CRAIG L NELSON
Credential	:	DOCTOR/OD
Telephone Number	:	719-589-9066

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	08/22/2020

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