Healthcare Provider Details

I. General information

NPI: 1184794745
Provider Name (Legal Business Name): MARC A PROVENCHER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 S TIMBERLINE RD UNIT 120
FORT COLLINS CO
80525-6023
US

IV. Provider business mailing address

4050 S TIMBERLINE RD UNIT 120
FORT COLLINS CO
80525-6023
US

V. Phone/Fax

Practice location:
  • Phone: 970-282-8888
  • Fax: 970-282-8484
Mailing address:
  • Phone: 970-282-8888
  • Fax: 970-282-8484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2025
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number209T
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2025
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: