Provider Demographics
NPI:1427232214
Name:MESA OPTICAL COMPANY INC
Entity type:Organization
Organization Name:MESA OPTICAL COMPANY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:W
Authorized Official - Last Name:TULL
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:970-242-4909
Mailing Address - Street 1:2232 N 7TH ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-7459
Mailing Address - Country:US
Mailing Address - Phone:970-242-4909
Mailing Address - Fax:970-243-7171
Practice Address - Street 1:2232 N 7TH ST
Practice Address - Street 2:SUITE 10
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-7459
Practice Address - Country:US
Practice Address - Phone:970-242-4909
Practice Address - Fax:970-243-7171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1426152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04021192Medicaid
CO0729640001Medicare NSC
CODQ5068Medicare PIN
C811415Medicare PIN