Provider Demographics
NPI:1568063881
Name:BRIGHT EYES VISION CLINIC PC A COLORADO PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BRIGHT EYES VISION CLINIC PC A COLORADO PROFESSIONAL CORPORATION
Other - Org Name:BRIGHT EYES VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:KILLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-276-0344
Mailing Address - Street 1:326 DOZIER AVE
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-2706
Mailing Address - Country:US
Mailing Address - Phone:719-276-0344
Mailing Address - Fax:
Practice Address - Street 1:550 THORNTON PKWY UNIT 222
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-2168
Practice Address - Country:US
Practice Address - Phone:303-920-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIGHT EYES VISION CLINIC PC A COLORADO PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-03
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000144056Medicaid