Basic Information
| Provider Information | |||||||||
| NPI: | 1023074291 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARIZONA EYE INSTITUTE & COSMETIC LASER CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19052 N R H JOHNSON BLVD | ||||||||
| Address2: | |||||||||
| City: | SUN CITY WEST | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853754401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239752020 | ||||||||
| FaxNumber: | 6239757005 | ||||||||
| Practice Location | |||||||||
| Address1: | 19052 N R H JOHNSON BLVD | ||||||||
| Address2: | |||||||||
| City: | SUN CITY WEST | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853754401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239752020 | ||||||||
| FaxNumber: | 6239757005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | JUSTO | ||||||||
| AuthorizedOfficialFirstName: | EMILIO | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6239752020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | OSC3384 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.