MEDICARE: ARCHULETA EYECARE ASSOCIATES, LLC

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	2532	CO

General Provider Information

NPI Number	:	1649205113
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARCHULETA EYECARE ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	190 TALISMAN DR UNIT B4
Second Line	:
City	:	PAGOSA SPRINGS
State	:	CO
Zip	:	81147-9171
Country	:	US
Telephone Number	:	505-263-4695
Fax Number	:

Provider Business Practice Location Address
First Line	:	190 TALISMAN DR UNIT B4
Second Line	:
City	:	PAGOSA SPRINGS
State	:	CO
Zip	:	81147-9171
Country	:	US
Telephone Number	:	970-731-4347
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JONATHAN ZISSMAN
Credential	:	O.D.
Telephone Number	:	970-713-4347

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	09/08/2021

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