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General NPI Number Information
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NPI Number | 1568752293
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Entity Type | Organization
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Legal Business Name | PETERSON FAMILY EYECARE
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Dates
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Enumeration Date | 04/14/2011
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Last Update Date | 04/25/2013
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Provider Practice Location Address
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Address Line | 6665 DELMONICO DR STE. A
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City | COLORADO SPRINGS
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State | CO
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Zip | 80919-6801
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Country | US
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Telephone | 719-599-9393
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Fax |
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Provider Business Mailing Address
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Address Line | 6665 DELMONICO DR STE. A
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City | COLORADO SPRINGS
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State | CO
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Zip | 80919-6801
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Country | US
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Telephone | 719-599-9393
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MATTHEW PETERSON
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Credential | O.D.
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Telephone | 719-599-9393
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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 | 2804
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License Number State | CO
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