Provider Demographics
NPI:1104067461
Name:FLATIRONS OPTICAL INC.
Entity type:Organization
Organization Name:FLATIRONS OPTICAL INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIILYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-443-3551
Mailing Address - Street 1:385 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-3344
Mailing Address - Country:US
Mailing Address - Phone:303-443-3551
Mailing Address - Fax:303-449-5383
Practice Address - Street 1:385 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-3344
Practice Address - Country:US
Practice Address - Phone:303-443-3551
Practice Address - Fax:303-449-5383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-17
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10608000000332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0361290001Medicare NSC