Basic Information
| Provider Information | |||||||||
| NPI: | 1609106145 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BARNET DULANEY PERKINS EYE CENTER | ||||||||
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| OtherOrganizationName: | BARNET DULANEY PERKINS EYE CENTER SHOW LOW | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 N 22ND ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029551000 | ||||||||
| FaxNumber: | 6025084830 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 S WHITE MOUNTAIN RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285373937 | ||||||||
| FaxNumber: | 9285374729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2010 | ||||||||
| LastUpdateDate: | 01/06/2010 | ||||||||
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| AuthorizedOfficialLastName: | SNYDER | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6029551000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 858 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 576689 | 05 | AZ | MEDICAID |