Basic Information
| Provider Information | |||||||||
| NPI: | 1437120334 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRESCOTT EYE CARE & SURGICAL CENTER PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3192 WILLOW CREEK RD | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863016610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287783950 | ||||||||
| FaxNumber: | 9287783999 | ||||||||
| Practice Location | |||||||||
| Address1: | 3192 WILLOW CREEK RD | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863016610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287783950 | ||||||||
| FaxNumber: | 9287783999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 02/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | MORTENSON | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | WORTHEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/ MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9284451234 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QS0132X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ophthalmologic Surgery |
No ID Information.