MEDICARE: LASER VISION OF FORT COLLINS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician		CO

General Provider Information

NPI Number	:	1093262024
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LASER VISION OF FORT COLLINS

Provider Business Mailing Address
First Line	:	3617 S COLLEGE AVE UNIT C
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3009
Country	:	US
Telephone Number	:	970-377-0600
Fax Number	:	970-797-1955

Provider Business Practice Location Address
First Line	:	3617 S COLLEGE AVE UNIT C
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3009
Country	:	US
Telephone Number	:	970-377-0600
Fax Number	:	970-797-1955

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RONALD FRENKEL
Credential	:
Telephone Number	:	757-348-5516

Provider Enumeration Date	:	09/07/2016
Last Update Date	:	09/07/2016

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