Healthcare Provider Details

I. General information

NPI: 1184747230
Provider Name (Legal Business Name): MONTE VISTA EYE CARE CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CHICO CT
MONTE VISTA CO
81144-1067
US

IV. Provider business mailing address

101 CHICO CT
MONTE VISTA CO
81144-1067
US

V. Phone/Fax

Practice location:
  • Phone: 719-852-3412
  • Fax: 719-852-3345
Mailing address:
  • Phone: 719-852-3412
  • Fax: 719-852-3345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number990
License Number StateCO

VIII. Authorized Official

Name: DR. PAUL WILLIAM HEERSINK
Title or Position: PRESIDENT
Credential: O.D.
Phone: 719-852-3412