Basic Information
| Provider Information | |||||||||
| NPI: | 1669802013 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYE BOUTIQUE OF SEDONA, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 HIGH VIEW DR | ||||||||
| Address2: | |||||||||
| City: | SEDONA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863516961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283010457 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 VERDE VALLEY SCHOOL RD | ||||||||
| Address2: | SUITE 114 | ||||||||
| City: | SEDONA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863519053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282399901 | ||||||||
| FaxNumber: | 9282399902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2013 | ||||||||
| LastUpdateDate: | 11/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | CHANG | ||||||||
| AuthorizedOfficialFirstName: | CAROLYN | ||||||||
| AuthorizedOfficialMiddleName: | JEANNE MARTIN | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9283010457 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1467 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 612863 | 05 | AZ | MEDICAID | 1255304754 | 01 | INDIVIDUAL NPI | OTHER |