1558996546 NPI number — THE EYE DOCTOR AT ST. ROSE LLC

Table of content: (NPI 1558996546)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558996546 NPI number — THE EYE DOCTOR AT ST. ROSE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE EYE DOCTOR AT ST. ROSE 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:
6
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:
1558996546
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
556 N EASTERN AVE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89101-3453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-385-7900
Provider Business Mailing Address Fax Number:
702-385-1116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2645 ST. ROSE PARKWAY
Provider Second Line Business Practice Location Address:
SUITE C-110
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-385-7900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/10/2020

Additional Information

Authorized Official

Authorized Official Last Name:
GAMMOH
Authorized Official First Name:
NATALY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/OPTOMETRIST
Authorized Official Telephone Number:
702-385-7900

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com