Healthcare Provider Details

I. General information

NPI: 1851930879
Provider Name (Legal Business Name): MIC OPTICAL SOURCING,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2019
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 W ALAMEDA AVE UNIT 16
DENVER CO
80223-1947
US

IV. Provider business mailing address

2200 W ALAMEDA AVE UNIT 16
DENVER CO
80223-1947
US

V. Phone/Fax

Practice location:
  • Phone: 720-238-2922
  • Fax: 720-572-7999
Mailing address:
  • Phone: 720-238-2922
  • Fax: 720-572-7999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: MR. GANG HE
Title or Position: OWNER
Credential: OPTICIAN
Phone: 720-238-2922