Provider Demographics
NPI:1538341722
Name:EYELAND, P.C.
Entity type:Organization
Organization Name:EYELAND, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:719-528-8148
Mailing Address - Street 1:1955 DOMINION WAY STE 110
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1480
Mailing Address - Country:US
Mailing Address - Phone:719-528-8148
Mailing Address - Fax:719-528-1819
Practice Address - Street 1:1955 DOMINION WAY STE 110
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1480
Practice Address - Country:US
Practice Address - Phone:719-528-8148
Practice Address - Fax:719-528-1819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03339271Medicaid