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DR. JORDAN BRETT BALLANTYNE O.D.
>> Optometrist >> Eye and Vision Services ProvidersRegistrant NPI Number: 1326352212
Individual Registrant:DR. JORDAN BRETT BALLANTYNE O.D.
Gender: M
Not Sole Proprietor
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
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
Tel: 719-383-0134 Fax: 719-404-1825
Registration Information:
NPI: 1326352212
Entity Type: Individual
Entity Type: Individual
Specialty information:
| Primary | Code | Category/Description | State | License Number |
|---|---|---|---|---|
| Y | 152W00000X | Eye and Vision Services Providers Optometrist | CO | 2799 |
Legacy codes, insurance codes and state license numbers:
| Issuer | Number | State | Type |
|---|---|---|---|
| 93920288 | CO | 05 | |
| CAQH | 12141883 | CO | 01 |
| MEDICARE INDIVIDUAL PTAN | COA105677 | CO | 01 |
