Basic Information
| Provider Information | |||||||||
| NPI: | 1780991661 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRESCOTT VALLEY OPTICAL, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3153 N WINDSONG DR | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863142240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287719939 | ||||||||
| FaxNumber: | 9287723972 | ||||||||
| Practice Location | |||||||||
| Address1: | 3153 N WINDSONG DR | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863142240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287719939 | ||||||||
| FaxNumber: | 9287723972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2010 | ||||||||
| LastUpdateDate: | 09/13/2010 | ||||||||
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| AuthorizedOfficialLastName: | COURTRIGHT | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9287719939 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | 909 | AZ | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
No ID Information.