Basic Information
| Provider Information | |||||||||
| NPI: | 1134120850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RHODES | ||||||||
| FirstName: | KRISTI | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 72802 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850501031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413909667 | ||||||||
| FaxNumber: | 4809614605 | ||||||||
| Practice Location | |||||||||
| Address1: | 29605 N CAVE CREEK RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | CAVE CREEK | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853312360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807814446 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2974T | OR | N | Eye and Vision Services Providers | Optometrist | 152WC0802X | 1846 | AZ | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152W00000X | 1846 | AZ | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 685453 | 05 | AZ | MEDICAID | 86-0884211 | 01 | TAX ID | OTHER |