Provider Demographics
NPI:1992894489
Name:OLDE TOWNE EYE CARE LLC
Entity type:Organization
Organization Name:OLDE TOWNE EYE CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRODIE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:303-772-6140
Mailing Address - Street 1:800 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-5928
Mailing Address - Country:US
Mailing Address - Phone:303-772-6140
Mailing Address - Fax:303-772-9128
Practice Address - Street 1:800 3RD AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5928
Practice Address - Country:US
Practice Address - Phone:303-772-6140
Practice Address - Fax:303-772-9128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC807429Medicare UPIN
CO5816400001Medicare NSC