Provider Demographics
NPI:1902400468
Name:ACADEMY KIDS VISION CENTER LLC
Entity Type:Organization
Organization Name:ACADEMY KIDS VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:URBANOZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-323-2362
Mailing Address - Street 1:2221 E BIJOU ST STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-8009
Mailing Address - Country:US
Mailing Address - Phone:719-576-1850
Mailing Address - Fax:
Practice Address - Street 1:2436 S ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80916-2408
Practice Address - Country:US
Practice Address - Phone:719-391-2336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACADEMY KIDS VISION CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO25100343Medicaid