1184769028 NPI number — AFFILIATED OPHTHALMIC SVC

Table of content: (NPI 1184769028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184769028 NPI number — AFFILIATED OPHTHALMIC SVC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AFFILIATED OPHTHALMIC SVC
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:
1184769028
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3500 E LINCOLN DR # 30
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:
85018-1010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-955-5104
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 W THOMAS RD
Provider Second Line Business Practice Location Address:
SUITE #250
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85013-4224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-263-9345
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLOEMKER
Authorized Official First Name:
E
Authorized Official Middle Name:
FREDRICK
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
602-955-5104

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CS2496 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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