Individual
DR. JORDAN BRETT BALLANTYNE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
302 W 3RD ST, LA JUNTA, CO 81050-1430
(719) 383-0134
(719) 404-1825
Mailing address
PO BOX 305, LA JUNTA, CO 81050-0305
(719) 383-0134
(719) 404-1825
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2799
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12141883
CAQH
CO
05
—
93920288
—
CO
01
—
COA105677
MEDICARE INDIVIDUAL PTAN
CO
Enumeration date
08/03/2010
Last updated
10/10/2016
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