1750455234 NPI number — SEVILLE EYE CENTER LLC

Table of content: (NPI 1750455234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750455234 NPI number — SEVILLE EYE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEVILLE EYE CENTER 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:
1750455234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3336 E CHANDLER HEIGHTS RD
Provider Second Line Business Mailing Address:
BLDG A STE 104
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85298-4259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-279-3937
Provider Business Mailing Address Fax Number:
480-889-2948

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3336 E CHANDLER HEIGHTS RD
Provider Second Line Business Practice Location Address:
BLDG A STE 104
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85298-4259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-279-3937
Provider Business Practice Location Address Fax Number:
480-889-2948
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARPENTER
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
480-279-3937

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  AZ01104 , 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)

  • Identifier: 539570 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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