Provider Demographics
NPI:1265836043
Name:AKVC CENTRAL LLC
Entity Type:Organization
Organization Name:AKVC CENTRAL LLC
Other - Org Name:ACADEMY KIDS DENTAL AND 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:719-442-0071
Mailing Address - Fax:719-473-5303
Practice Address - Street 1:883 N ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-8307
Practice Address - Country:US
Practice Address - Phone:714-442-0071
Practice Address - Fax:719-473-5303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200871800AMedicaid
MO310087377Medicaid
NM27952291Medicaid
DCOP1000412OtherSTATE
KS200532530CMedicaid
MDDA2086OtherSTATE
KS1796OtherSTATE
COOPT.0001462OtherSTATE
NMOPT732OtherSTATE
MD016627801Medicaid
DC019177299Medicaid
CO97789054Medicaid
OK3033OtherSTATE