Healthcare Provider Details

I. General information

NPI: 1033716212
Provider Name (Legal Business Name): MADISON STREET PROVIDER NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1371 HECLA DR STE C
LOUISVILLE CO
80027-2318
US

IV. Provider business mailing address

PO BOX 912914
DENVER CO
80291-2914
US

V. Phone/Fax

Practice location:
  • Phone: 303-666-7226
  • Fax: 303-665-3367
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: GEORGE L NEAL
Title or Position: PRESIDENT
Credential:
Phone: 469-214-0144