Provider Demographics
NPI:1194713057
Name:CCC OPTICAL PC
Entity type:Organization
Organization Name:CCC OPTICAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:L
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTOR/OD
Authorized Official - Phone:719-589-9066
Mailing Address - Street 1:2509 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2239
Mailing Address - Country:US
Mailing Address - Phone:719-589-9066
Mailing Address - Fax:719-589-4079
Practice Address - Street 1:190 TALISMAN DR
Practice Address - Street 2:SUITE B4
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-9171
Practice Address - Country:US
Practice Address - Phone:970-731-4347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1409152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO43133Medicare ID - Type Unspecified
U36980Medicare UPIN