=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700247228
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HV PUEBLO SOUTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2016
-----------------------------------------------------
Last Update Date | 04/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1725 S PUEBLO BLVD
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81005-2103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-281-2633
-----------------------------------------------------
Fax | 719-281-2634
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2221 E BIJOU ST STE 100
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-281-2633
-----------------------------------------------------
Fax | 719-281-2634
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | MS. SAMANTHA B LEBLANC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 719-323-2372
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------