Basic Information
| Provider Information | |||||||||
| NPI: | 1730368275 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVENTURE VISION LLC | ||||||||
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| OtherOrganizationName: | ADVENTURE 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: | 3168322838 | ||||||||
| FaxNumber: | 3168329530 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 W 21ST ST. | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672032106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168322838 | ||||||||
| FaxNumber: | 3168329530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 04/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | LEBLANC | ||||||||
| AuthorizedOfficialFirstName: | SAMANTHA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7193232372 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 200536800A | 05 | KS | MEDICAID |