Healthcare Provider Details

I. General information

NPI: 1861945925
Provider Name (Legal Business Name): WHITE MOUNTAIN EYE INSTITUTE PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 E 1ST ST
EAGAR AZ
85925-9847
US

IV. Provider business mailing address

39 E 1ST ST
EAGAR AZ
85925-9847
US

V. Phone/Fax

Practice location:
  • Phone: 928-333-4396
  • Fax: 928-333-5050
Mailing address:
  • Phone: 928-333-4396
  • Fax: 928-333-5050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1530
License Number StateAZ

VIII. Authorized Official

Name: DR. KAYLE LAMAR HAWS
Title or Position: OWNER/PROVIDER
Credential: O.D.
Phone: 928-581-2825