MEDICARE: RODEO VISION ACADEMY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

General Provider Information

NPI Number	:	1386327948
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RODEO VISION ACADEMY LLC

Provider Business Mailing Address
First Line	:	5150 N ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-4002
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5150 N ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-4002
Country	:	US
Telephone Number	:	760-978-8527
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MICHAEL HERRERA
Credential	:	MBA
Telephone Number	:	760-978-8527

Provider Enumeration Date	:	08/10/2023
Last Update Date	:	08/10/2023

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