Provider Demographics
NPI:1619624632
Name:OPTOM-EYES,LLC
Entity Type:Organization
Organization Name:OPTOM-EYES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:936-443-4151
Mailing Address - Street 1:3585 VAN TEYLINGEN DR STE B
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-4872
Mailing Address - Country:US
Mailing Address - Phone:936-443-4151
Mailing Address - Fax:
Practice Address - Street 1:3585 VAN TEYLINGEN DR STE B
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-4872
Practice Address - Country:US
Practice Address - Phone:936-443-4151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO351521ZGYBMedicaid