Basic Information
Provider Information | |||||||||
NPI: | 1740431378 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRESCOTT EYE CARE & SURGICAL CENTER, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3192 WILLOW CREEK RD | ||||||||
Address2: |   | ||||||||
City: | PRESCOTT | ||||||||
State: | AZ | ||||||||
PostalCode: | 863016610 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9284451234 | ||||||||
FaxNumber: | 9287728107 | ||||||||
Practice Location | |||||||||
Address1: | 3769 CROSSING DRIVE | ||||||||
Address2: |   | ||||||||
City: | PRESCOTT | ||||||||
State: | AZ | ||||||||
PostalCode: | 863051606 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9284459200 | ||||||||
FaxNumber: | 9287728107 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/01/2008 | ||||||||
LastUpdateDate: | 05/24/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORTENSON | ||||||||
AuthorizedOfficialFirstName: | STEVEN | ||||||||
AuthorizedOfficialMiddleName: | W. | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9284459200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1100X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Ophthalmic |
No ID Information.