Basic Information
| Provider Information | |||||||||
| NPI: | 1265836043 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AKVC CENTRAL LLC | ||||||||
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| OtherOrganizationName: | ACADEMY KIDS DENTAL AND VISION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST. | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194420071 | ||||||||
| FaxNumber: | 7194735303 | ||||||||
| Practice Location | |||||||||
| Address1: | 883 N ACADEMY BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144420071 | ||||||||
| FaxNumber: | 7194735303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2014 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | LEBLANC | ||||||||
| AuthorizedOfficialFirstName: | SAMANTHA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7193232372 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 152WP0200X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200871800A | 05 | OK | MEDICAID | 310087377 | 05 | MO | MEDICAID | 27952291 | 05 | NM | MEDICAID | OP1000412 | 01 | DC | STATE | OTHER | 200532530C | 05 | KS | MEDICAID | DA2086 | 01 | MD | STATE | OTHER | 1796 | 01 | KS | STATE | OTHER | OPT.0001462 | 01 | CO | STATE | OTHER | OPT732 | 01 | NM | STATE | OTHER | 016627801 | 05 | MD | MEDICAID | 019177299 | 05 | DC | MEDICAID | 97789054 | 05 | CO | MEDICAID | 3033 | 01 | OK | STATE | OTHER |