Provider Demographics
NPI:1356675557
Name:MOUNTAIN SHADOWS VISION CENTER, LLC
Entity Type:Organization
Organization Name:MOUNTAIN SHADOWS VISION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGASHI-REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-590-1744
Mailing Address - Street 1:1910 VINDICATOR DR STE 102
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3618
Mailing Address - Country:US
Mailing Address - Phone:719-590-1744
Mailing Address - Fax:
Practice Address - Street 1:1910 VINDICATOR DR STE 102
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3618
Practice Address - Country:US
Practice Address - Phone:719-590-1744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO1914152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty