Healthcare Provider Details

I. General information

NPI: 1558544833
Provider Name (Legal Business Name): FORT LUPTON VISION CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2007
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 DENVER AVE
FORT LUPTON CO
80621-1821
US

IV. Provider business mailing address

301 DENVER AVE
FORT LUPTON CO
80621-1821
US

V. Phone/Fax

Practice location:
  • Phone: 303-857-6550
  • Fax: 303-857-6596
Mailing address:
  • Phone: 303-857-6550
  • Fax: 303-857-6596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2357
License Number StateCO

VIII. Authorized Official

Name: DR. DAVID A SIMONSON
Title or Position: PRESIDENT
Credential: OD
Phone: 303-857-6550