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General NPI Number Information
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NPI Number | 1093229718
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Entity Type | Organization
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Legal Business Name | FORT MORGAN EYE CARE LLC
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Dates
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Enumeration Date | 11/17/2017
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Last Update Date | 01/11/2018
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Provider Practice Location Address
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Address Line | 1100 MAIN ST
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City | FORT MORGAN
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State | CO
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Zip | 80701-2036
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Country | US
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Telephone | 970-867-3046
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Fax |
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Provider Business Mailing Address
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Address Line | 1100 MAIN ST
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City | FORT MORGAN
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State | CO
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Zip | 80701-2036
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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 | OPTOMETRIST
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Name | DR. JEFFREY RYAN WIEDRICH
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Credential | O.D.
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Telephone | 806-336-7105
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | OPT.0002664
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License Number State | CO
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