Healthcare Provider Details

I. General information

NPI: 1942446083
Provider Name (Legal Business Name): MOULTON FAMILY EYE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2008
Last Update Date: 12/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 S IDAHO RD SUITE 105B
APACHE JUNCTION AZ
85119-6496
US

IV. Provider business mailing address

1075 S IDAHO RD SUITE 105B
APACHE JUNCTION AZ
85119-6496
US

V. Phone/Fax

Practice location:
  • Phone: 480-380-5116
  • Fax: 480-380-0791
Mailing address:
  • Phone: 480-380-5116
  • Fax: 480-380-0791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1452
License Number StateAZ

VIII. Authorized Official

Name: DR. JASON HUGH MOULTON
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 480-380-5116