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General NPI Number Information
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NPI Number | 1154487320
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Entity Type | Organization
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Legal Business Name | FRONT RANGE OPTICAL
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Dates
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Enumeration Date | 12/29/2006
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Last Update Date | 01/22/2009
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Provider Practice Location Address
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Address Line | 1319 VIVIAN ST
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City | LONGMONT
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State | CO
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Zip | 80501
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Country | US
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Telephone | 303-772-3818
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Fax |
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Provider Business Mailing Address
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Address Line | 1319 VIVIAN ST
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City | LONGMONT
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State | CO
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Zip | 80501-3216
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Country | US
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Telephone | 303-772-3818
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. DALE S JOHNSON
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Credential | M.C.
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Telephone | 303-772-3818
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 07-69569-0000
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License Number State | CO
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