=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902080716
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROCKETT VISION CENTER INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2007
-----------------------------------------------------
Last Update Date | 02/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1345 WADSWORTH BLVD
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80214-4209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-238-9900
-----------------------------------------------------
Fax | 303-238-8527
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1345 WADSWORTH BLVD
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80214-4209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-238-9900
-----------------------------------------------------
Fax | 303-238-8527
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/ OPTOMETRIST
-----------------------------------------------------
Name | DR. DAVID KIM CROCKETT
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 303-238-9900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ESP1196
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------