=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598333163
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ONE HOUR OPTICAL MEDICAL SERVICES, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2021
-----------------------------------------------------
Last Update Date | 06/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1113 S ABILENE CT STE 100
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80012-4655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-755-9447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 E CAMPBELL ROAD SUITE 108 PMB 679402
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-462-9818
-----------------------------------------------------
Fax | 314-741-4947
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STACY LYNN HIEB
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 303-487-4432
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------