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DR. JORDAN BRETT BALLANTYNE O.D.

>> Optometrist >> Eye and Vision Services Providers

Registrant NPI Number: 1326352212

Individual Registrant:
DR. JORDAN BRETT BALLANTYNE O.D.
Gender: M
Not Sole Proprietor

Location and contact information for practice:
302 W 3RD ST  LA JUNTA, CO 81050-1430 US
Tel: 719-383-0134  Fax: 719-404-1825

Contact information for business:
PO BOX 305  LA JUNTA, CO 81050-0305 US
Tel: 719-383-0134  Fax: 719-404-1825

Registration Information:
NPI: 1326352212
Entity Type: Individual

Specialty information:

PrimaryCodeCategory/DescriptionStateLicense Number
Y152W00000XEye and Vision Services Providers
Optometrist
CO2799

Legacy codes, insurance codes and state license numbers:

IssuerNumberStateType
93920288CO05
CAQH12141883CO01
MEDICARE INDIVIDUAL PTANCOA105677CO01




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