Healthcare Provider Details

I. General information

NPI: 1114101136
Provider Name (Legal Business Name): SAN TAN EYECARE PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 S VAL VISTA DR SUITE 111
GILBERT AZ
85295-1606
US

IV. Provider business mailing address

2680 S VAL VISTA DR SUITE 111
GILBERT AZ
85295-1606
US

V. Phone/Fax

Practice location:
  • Phone: 480-807-0288
  • Fax: 480-290-7199
Mailing address:
  • Phone: 480-807-0288
  • Fax: 480-290-7199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number349
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1307
License Number StateAZ

VIII. Authorized Official

Name: DR. JACK L HOSTETLER
Title or Position: MEMBER
Credential: OD
Phone: 480-807-0288