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General NPI Number Information
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NPI Number | 1356675557
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Entity Type | Organization
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Legal Business Name | MOUNTAIN SHADOWS VISION CENTER, LLC
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Dates
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Enumeration Date | 09/22/2009
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Last Update Date | 12/31/2020
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Provider Practice Location Address
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Address Line | 1910 VINDICATOR DR STE 102
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City | COLORADO SPRINGS
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State | CO
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Zip | 80919-3618
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Country | US
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Telephone | 719-590-1744
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Fax |
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Provider Business Mailing Address
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Address Line | 1910 VINDICATOR DR STE 102
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City | COLORADO SPRINGS
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State | CO
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Zip | 80919-3618
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Country | US
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Telephone | 719-590-1744
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | KAREN HIGASHI-REYNOLDS
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Credential |
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Telephone | 719-590-1744
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | CO1914
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License Number State | CO
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