Basic Information
| Provider Information | |||||||||
| NPI: | 1184184129 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HERO VISION OF UTICA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195701850 | ||||||||
| FaxNumber: | 7199553470 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 S UTICA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741042641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185853744 | ||||||||
| FaxNumber: | 7199553470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2019 | ||||||||
| LastUpdateDate: | 09/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | SOUDER | ||||||||
| AuthorizedOfficialFirstName: | CHARLOTTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7195761850 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.