Provider Demographics
NPI:1194271965
Name:VISION REVISION PC
Entity type:Organization
Organization Name:VISION REVISION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:GROVES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-686-6066
Mailing Address - Street 1:1292 MAIN ST #3
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550
Mailing Address - Country:US
Mailing Address - Phone:970-686-6066
Mailing Address - Fax:
Practice Address - Street 1:1292 MAIN ST UNIT 3
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-5965
Practice Address - Country:US
Practice Address - Phone:970-686-6066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO1983152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty