=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205075678
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEEPER OPTICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2009
-----------------------------------------------------
Last Update Date | 02/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5075 LEETSDALE DR
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80246-8176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-333-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5075 LEETSDALE DR
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80246-8176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-333-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MANSUR NURDEL
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 303-333-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1319
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------