Healthcare Provider Details

I. General information

NPI: 1629244470
Provider Name (Legal Business Name): RICHARD & MARCIA STAUTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 03/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3545 W 12TH ST STE. 101
GREELEY CO
80634-2545
US

IV. Provider business mailing address

3545 W 12TH ST STE. 101
GREELEY CO
80634-2545
US

V. Phone/Fax

Practice location:
  • Phone: 970-352-4200
  • Fax: 970-352-4278
Mailing address:
  • Phone: 970-352-4200
  • Fax: 970-352-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1282
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1282
License Number StateCO

VIII. Authorized Official

Name: DR. MARCIA SCHULTE STAUTER
Title or Position: OWNER
Credential: O.D.
Phone: 970-352-4200