1659343648 NPI number — SWAGEL-WOOTTON EYE CENTER, INC

Table of content: (NPI 1659343648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659343648 NPI number — SWAGEL-WOOTTON EYE CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SWAGEL-WOOTTON EYE CENTER, INC
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:
1659343648
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 200414
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75320-3941
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-514-1001
Provider Business Mailing Address Fax Number:
205-241-1217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 S 63RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85206-1619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-641-3937
Provider Business Practice Location Address Fax Number:
480-924-5094
Provider Enumeration Date:
02/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ELLISON
Authorized Official First Name:
CHRISTIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
720-273-7449

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  OSC0063 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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