Healthcare Provider Details

I. General information

NPI: 1376612143
Provider Name (Legal Business Name): EATON VISION CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 08/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 ELM AVE
EATON CO
80615-3428
US

IV. Provider business mailing address

215 ELM AVE
EATON CO
80615-3428
US

V. Phone/Fax

Practice location:
  • Phone: 970-454-3387
  • Fax: 970-454-3380
Mailing address:
  • Phone: 970-454-3387
  • Fax: 970-454-3380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT 1014
License Number StateCO

VIII. Authorized Official

Name: MICHAEL C STURM
Title or Position: PARTNER
Credential: O.D.
Phone: 970-454-3387