Provider Demographics
NPI:1902080716
Name:CROCKETT VISION CENTER INC.
Entity type:Organization
Organization Name:CROCKETT VISION CENTER INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:303-238-9900
Mailing Address - Street 1:1345 WADSWORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80214-4209
Mailing Address - Country:US
Mailing Address - Phone:303-238-9900
Mailing Address - Fax:303-238-8527
Practice Address - Street 1:1345 WADSWORTH BLVD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80214-4209
Practice Address - Country:US
Practice Address - Phone:303-238-9900
Practice Address - Fax:303-238-8527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COESP1196152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0171790001Medicare NSC
COC383008Medicare PIN