1962943118 NPI number — SPECTRA EYE INSTITUTE, LLC

Table of content: (NPI 1962943118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962943118 NPI number — SPECTRA EYE INSTITUTE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECTRA EYE INSTITUTE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962943118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15401 N 29TH AVE STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85053-4000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-583-2020
Provider Business Mailing Address Fax Number:
623-583-2075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15401 N 29TH AVE
Provider Second Line Business Practice Location Address:
201
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85053-4001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-583-2020
Provider Business Practice Location Address Fax Number:
623-583-2513
Provider Enumeration Date:
03/20/2017

Additional Information

Authorized Official

Authorized Official Last Name:
AMATOR
Authorized Official First Name:
JAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
623-583-2020

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QS0132X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 544256 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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