Basic Information
Provider Information
NPI: 1295339745
EntityType: 2
ReplacementNPI:  
OrganizationName: AKVC NORTH LLC
LastName:  
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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:  
Practice Location
Address1: 3630 AUSTIN BLUFFS PKWY STE 100-120
Address2:  
City: COLORADO SPRINGS
State: CO
PostalCode: 809186661
CountryCode: US
TelephoneNumber: 7192680146
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/25/2020
LastUpdateDate: 11/25/2020
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: URBANOZO
AuthorizedOfficialFirstName: SHAUN
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AuthorizedOfficialTitleorPosition: CREDENTIALING MANAGER
AuthorizedOfficialTelephone: 7193232362
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: AKVC NORTH LLC
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NPICertificationDate: 11/23/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000X  Y193400000X SINGLE SPECIALTY GROUPEye and Vision Services ProvidersOptometrist 

ID Information
IDTypeStateIssuerDescription
6687477705CO MEDICAID


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