Provider Demographics
NPI:1811102759
Name:NORTH FORK VISION CENTER INC
Entity type:Organization
Organization Name:NORTH FORK VISION CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:REDDIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-872-2020
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:HOTCHKISS
Mailing Address - State:CO
Mailing Address - Zip Code:81419-0658
Mailing Address - Country:US
Mailing Address - Phone:970-872-2020
Mailing Address - Fax:970-872-2022
Practice Address - Street 1:210 E. BRIDGE STREET
Practice Address - Street 2:
Practice Address - City:HOTCHKISS
Practice Address - State:CO
Practice Address - Zip Code:81419
Practice Address - Country:US
Practice Address - Phone:970-872-2020
Practice Address - Fax:970-872-2022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1335152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO60733837Medicaid
C479288Medicare PIN
CO60733837Medicaid