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General NPI Number Information
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NPI Number | 1447794409
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Entity Type | Organization
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Legal Business Name | REDSTONE EYE CARE
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Dates
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Enumeration Date | 12/10/2016
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Last Update Date | 12/10/2016
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Provider Practice Location Address
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Address Line | 1200 S HOVER ST
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City | LONGMONT
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State | CO
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Zip | 80501-7902
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Country | US
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Telephone | 303-845-4215
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Fax | 303-682-8181
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Provider Business Mailing Address
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Address Line | 1200 S HOVER ST
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City | LONGMONT
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State | CO
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Zip | 80501-7902
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Country | US
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Telephone | 303-845-4215
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Fax | 303-682-8181
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. JUSTIN DANIEL DEAL
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Credential | O.D.
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Telephone | 812-881-8899
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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 | 2875
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License Number State | CO
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