=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609036912
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECTRUM EYE CARE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2008
-----------------------------------------------------
Last Update Date | 07/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13530 NORTHGATE ESTATES DR STE 200
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80921-7651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-593-2333
-----------------------------------------------------
Fax | 719-593-0012
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1839 BRIARGATE BLVD
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80920-3470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-593-2333
-----------------------------------------------------
Fax | 719-593-0012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARK DANIEL BENNETT
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 719-593-2333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------