Provider Demographics
NPI:1215925565
Name:CECIL, AMY C (OD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:C
Last Name:CECIL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 ELK RUN DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621-9205
Mailing Address - Country:US
Mailing Address - Phone:970-927-5107
Mailing Address - Fax:970-927-5108
Practice Address - Street 1:100 ELK RUN DR
Practice Address - Street 2:SUITE 206
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-9205
Practice Address - Country:US
Practice Address - Phone:970-927-5107
Practice Address - Fax:970-927-5108
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1261152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO52027732Medicaid
CO52027732Medicaid
COCO300083Medicare PIN
CO4409690001Medicare NSC