Healthcare Provider Details

I. General information

NPI: 1184766438
Provider Name (Legal Business Name): EYE SURGERY CENTER OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8402 CLAY ST STE.4
WESTMINSTER CO
80031-3847
US

IV. Provider business mailing address

8402 CLAY ST STE.4
WESTMINSTER CO
80031-3847
US

V. Phone/Fax

Practice location:
  • Phone: 303-426-8812
  • Fax: 303-657-5597
Mailing address:
  • Phone: 303-426-8812
  • Fax: 303-657-5597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number20828
License Number StateCO

VIII. Authorized Official

Name: DR. WILLIAM G SELF JR.
Title or Position: OWNER
Credential: M.D
Phone: 303-426-8812