Basic Information
| Provider Information | |||||||||
| NPI: | 1144821174 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRIGHT EYES VISION CLINIC PC A COLORADO PROFESSIONAL CORPORATION | ||||||||
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| OtherOrganizationName: | BRIGHT EYES FAMILY VISION CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 326 DOZIER AVE | ||||||||
| Address2: | |||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812122706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192760344 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5385 W 38TH AVE | ||||||||
| Address2: | |||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802127058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034766292 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2020 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | KILLEN | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7192760344 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BRIGHT EYES VISION CLINIC PC A COLORADO PROFESSIONAL CORPORATION | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 9000144069 | 05 | CO | MEDICAID |