Basic Information
| Provider Information | |||||||||
| NPI: | 1548582448 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ONE HOUR OPTICAL MEDICAL SERVICES, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | EYECARE SPECIALTIES OF COLORADO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1685 S COLORADO BLVD | ||||||||
| Address2: | UNIT O | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802224000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037576747 | ||||||||
| FaxNumber: | 3037576897 | ||||||||
| Practice Location | |||||||||
| Address1: | 1113 S. ABILENE ST. | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037559447 | ||||||||
| FaxNumber: | 3037552140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2010 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HIEB | ||||||||
| AuthorizedOfficialFirstName: | STACY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3034500200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1746 | CO | N | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 152W00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 28000277 | 05 | CO | MEDICAID | S4503 | 01 | PTAN | OTHER | 566838004 | 01 | CO | MEDICARE DME | OTHER |