Healthcare Provider Details

I. General information

NPI: 1366621104
Provider Name (Legal Business Name): IDRS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42201 N 41ST DR STE 144
ANTHEM AZ
85086-3802
US

IV. Provider business mailing address

42201 N 41ST DR STE 144
ANTHEM AZ
85086-3802
US

V. Phone/Fax

Practice location:
  • Phone: 623-551-9122
  • Fax: 623-551-9120
Mailing address:
  • Phone: 623-551-9122
  • Fax: 623-551-9120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1146
License Number StateAZ

VIII. Authorized Official

Name: DR. THOMAS ROBERT CZYZ
Title or Position: OWNER / TREASURER
Credential: OD
Phone: 623-551-9122