Basic Information
| Provider Information | |||||||||
| NPI: | 1700247228 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HV PUEBLO SOUTH LLC | ||||||||
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| OtherOrganizationName: | ACADEMY KIDS 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: | 7192812633 | ||||||||
| FaxNumber: | 7192812634 | ||||||||
| Practice Location | |||||||||
| Address1: | 1725 S PUEBLO BLVD | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810052103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192812633 | ||||||||
| FaxNumber: | 7192812634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2016 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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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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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 68820071 | 05 | CO | MEDICAID |