1962762765 NPI number — HERO VISION OF DENVER LLC

Table of content: (NPI 1962762765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962762765 NPI number — HERO VISION OF DENVER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERO VISION OF DENVER 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:
1962762765
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:
720-214-4746
Provider Business Mailing Address Fax Number:
720-214-4745

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1407 W 84TH AVE UNIT B8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80260-4753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-214-4746
Provider Business Practice Location Address Fax Number:
720-214-4745
Provider Enumeration Date:
05/25/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LEBLANC
Authorized Official First Name:
SAMANTHA
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
719-323-2372

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: 65779843 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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