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General NPI Number Information
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NPI Number | 1598530750
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Entity Type | Organization
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Legal Business Name | OUT THERE EYECARE LLC
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Dates
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Enumeration Date | 11/17/2023
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Last Update Date | 11/17/2023
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Provider Practice Location Address
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Address Line | 1510 W MAIN ST
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City | STERLING
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State | CO
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Zip | 80751-9095
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Country | US
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Telephone | 970-522-9095
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Fax | 970-522-5953
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Provider Business Mailing Address
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Address Line | 10990 COUNTY ROAD 28
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City | OVID
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State | CO
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Zip | 80744-9430
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Country | US
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Telephone | 970-522-9192
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Fax | 970-522-5953
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Authorized Official
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Title or Position | PROVIDER/OWNER
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Name | JAKE BALLARD LUMPKIN
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Credential | OD
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Telephone | 731-431-6078
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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 |
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License Number State |
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