Provider Demographics
NPI:1184821126
Name:YOUR CHILDS EYES LLC
Entity Type:Organization
Organization Name:YOUR CHILDS EYES LLC
Other - Org Name:ACADEMY KIDS VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEBLANC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-323-2372
Mailing Address - Street 1:2221 E BIJOU ST.
Mailing Address - Street 2:STE. 100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909
Mailing Address - Country:US
Mailing Address - Phone:719-329-1221
Mailing Address - Fax:719-329-1511
Practice Address - Street 1:2857 E FOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-2312
Practice Address - Country:US
Practice Address - Phone:719-329-1221
Practice Address - Fax:719-329-1511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1462152W00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21351821Medicaid