Provider Demographics
NPI:1730366808
Name:MITCHELL J MAYO
Entity type:Organization
Organization Name:MITCHELL J MAYO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYO
Authorized Official - Suffix:
Authorized Official - Credentials:BCO
Authorized Official - Phone:719-272-6416
Mailing Address - Street 1:2155 HOLLOW BROOK DR
Mailing Address - Street 2:STE 40
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1451
Mailing Address - Country:US
Mailing Address - Phone:719-272-6416
Mailing Address - Fax:719-272-6408
Practice Address - Street 1:2155 HOLLOW BROOK DR
Practice Address - Street 2:STE 40
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1451
Practice Address - Country:US
Practice Address - Phone:719-272-6416
Practice Address - Fax:719-272-6408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07137214Medicaid
4411770001Medicare NSC