Healthcare Provider Details

I. General information

NPI: 1992962658
Provider Name (Legal Business Name): MONIQUE MIKULA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 970-356-9743
  • Fax: 970-352-4278
Mailing address:
  • Phone: 970-356-9743
  • Fax: 970-352-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT1684
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberOPT1684
License Number StateCO

VIII. Authorized Official

Name: MONIQUE RENE' MIKULA
Title or Position: OWNER/OPTOMETRIST
Credential: O.D.
Phone: 970-356-9743