Basic Information
| Provider Information | |||||||||
| NPI: | 1154975472 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HERO VISION OF COMMERCE CITY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVENTURE DENTAL AND VISION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
| FaxNumber: | 7199553470 | ||||||||
| Practice Location | |||||||||
| Address1: | 6075 E PARKWAY DR STE 160 | ||||||||
| Address2: | |||||||||
| City: | COMMERCE CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800225413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7207957077 | ||||||||
| FaxNumber: | 7199553470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2019 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | URBANOZO | ||||||||
| AuthorizedOfficialFirstName: | SHAUN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7195761850 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
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 | OPT.0001462 | 01 | CO | STATE LICENSE | OTHER |