Healthcare Provider Details

I. General information

NPI: 1184612616
Provider Name (Legal Business Name): CCC OPTICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 01/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 WOLVERINE DR SUITE 5
BAYFIELD CO
81122-9653
US

IV. Provider business mailing address

98 TOKE LN
SOUTH FORK CO
81154-9448
US

V. Phone/Fax

Practice location:
  • Phone: 970-884-6188
  • Fax: 970-884-2869
Mailing address:
  • Phone: 719-658-0704
  • Fax: 719-658-0774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1409
License Number StateCO

VIII. Authorized Official

Name: DR. CRAIG L NELSON
Title or Position: DOCTOR/OPTOMETRIST
Credential: OD
Phone: 719-658-0704