Provider Demographics
NPI:1104344894
Name:LONGMONT EYECARE, PLLC
Entity type:Organization
Organization Name:LONGMONT EYECARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/CEO
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:720-652-0455
Mailing Address - Street 1:2285 E KEN PRATT BLVD
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-5223
Mailing Address - Country:US
Mailing Address - Phone:720-652-0455
Mailing Address - Fax:303-532-3269
Practice Address - Street 1:2285 E KEN PRATT BLVD
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80504-5223
Practice Address - Country:US
Practice Address - Phone:720-652-0455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-01
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003344152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty