1194021386 NPI number — HERO VISION OF LONGMONT, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194021386 NPI number — HERO VISION OF LONGMONT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERO VISION OF LONGMONT, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ADVENTURE DENTAL VISION AND ORTHONDONTICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194021386
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2221 E BIJOU ST
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-834-6400
Provider Business Mailing Address Fax Number:
303-834-6414

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1739 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGMONT
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80501-2035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-834-6400
Provider Business Practice Location Address Fax Number:
303-834-6414
Provider Enumeration Date:
02/04/2011

Additional Information

Authorized Official

Authorized Official Last Name:
URBANOZO
Authorized Official First Name:
SHAUN
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
719-323-2362

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 78105081 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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