Basic Information
| Provider Information | |||||||||
| NPI: | 1972782936 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HERO VISION OF WICHITA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVENTURE VISION OF WICHITA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 W 21ST ST N | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672032106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1255 LAKE PLAZA DR | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809063500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2007 | ||||||||
| LastUpdateDate: | 10/26/2007 | ||||||||
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| AuthorizedOfficialLastName: | PHARRIS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7195761850 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1796 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.