MEDICARE: OPTOM-EYES,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	261Q00000X	Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619624632
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTOM-EYES,LLC

Provider Business Mailing Address
First Line	:	3585 VAN TEYLINGEN DR STE B
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-4872
Country	:	US
Telephone Number	:	936-443-4151
Fax Number	:

Provider Business Practice Location Address
First Line	:	3585 VAN TEYLINGEN DR STE B
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-4872
Country	:	US
Telephone Number	:	936-443-4151
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	AMANDA WALLS
Credential	:	OD
Telephone Number	:	936-443-4151

Provider Enumeration Date	:	03/09/2022
Last Update Date	:	03/09/2022

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Directions to “OPTOM-EYES,LLC ” Practice Location

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