Basic Information
Provider Information | |||||||||
NPI: | 1144645391 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHWESTERN EYE CENTER LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTHWESTERN EYE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2610 E UNIVERSITY DR | ||||||||
Address2: |   | ||||||||
City: | MESA | ||||||||
State: | AZ | ||||||||
PostalCode: | 852138436 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4808928400 | ||||||||
FaxNumber: | 4808921889 | ||||||||
Practice Location | |||||||||
Address1: | 100 VERDE VALLEY ROAD | ||||||||
Address2: | STE 114 | ||||||||
City: | SEDONA | ||||||||
State: | AZ | ||||||||
PostalCode: | 86351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282399901 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/25/2014 | ||||||||
LastUpdateDate: | 02/25/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MUMFORD | ||||||||
AuthorizedOfficialFirstName: | SARAH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CONTRACTING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 4808928400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
No ID Information.