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General NPI Number Information
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NPI Number | 1073847802
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL VISIONCARE OF COLORADO LLC
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Dates
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Enumeration Date | 09/25/2009
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Last Update Date | 09/25/2009
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Provider Practice Location Address
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Address Line | 1040 INDEPENDENT AVE
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City | GRAND JUNCTION
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State | CO
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Zip | 81505-7133
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Country | US
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Telephone | 970-254-2880
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Fax |
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Provider Business Mailing Address
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Address Line | 772 JASPER DR
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City | FRUITA
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State | CO
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Zip | 81521-8312
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | BENJAMIN COLLINS
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Credential | O.D.
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Telephone | 801-709-8623
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2739
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License Number State | CO
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