MEDICARE: ARCHDALE EYECARE PC

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	152W00000X	Optometrist	1466	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	1588660161	OTHER	PERSONAL NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154457687
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARCHDALE EYECARE PC

Provider Business Mailing Address
First Line	:	1541 S 8TH ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80905-1923
Country	:	US
Telephone Number	:	719-577-4400
Fax Number	:	719-577-4954

Provider Business Practice Location Address
First Line	:	1541 S 8TH ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80905-1923
Country	:	US
Telephone Number	:	719-577-4400
Fax Number	:	719-577-4954

Authorized Official
Title or Position	:	OWNER
Name	:	THEODORE (TED) ARCHDALE
Credential	:	OD
Telephone Number	:	719-577-4400

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	11/23/2010

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Directions to “ARCHDALE EYECARE PC ” Practice Location

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