1710947098 NPI number — MARTIN VISION PC

Table of content: (NPI 1710947098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710947098 NPI number — MARTIN VISION PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARTIN VISION PC
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:
MARTIN VISION PC
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:
1710947098
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13505 HERRING RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80908-2946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-282-8555
Provider Business Mailing Address Fax Number:
718-282-8555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
388 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80911-1713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-391-2000
Provider Business Practice Location Address Fax Number:
844-273-2910
Provider Enumeration Date:
03/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
719-660-2162

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1784 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 99382041 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06002242 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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