Healthcare Provider Details

I. General information

NPI: 1609387703
Provider Name (Legal Business Name): BLUE RIVER VISION PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2017
Last Update Date: 01/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

358 BLUE RIVER PKWY SUITE D
SILVERTHORNE CO
80498
US

IV. Provider business mailing address

P.O. BOX 402 PMB 310
DILLON CO
80435-0402
US

V. Phone/Fax

Practice location:
  • Phone: 303-503-6397
  • Fax:
Mailing address:
  • Phone: 970-368-6539
  • Fax: 970-368-6539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2671
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number2671
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number2671
License Number StateCO

VIII. Authorized Official

Name: DR. JESSICA J HEGEWALD
Title or Position: OPTOMETRIST / OWNER
Credential: OD
Phone: 970-368-6539