Healthcare Provider Details

I. General information

NPI: 1548942923
Provider Name (Legal Business Name): EYES EARS & VITALITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15396 N 83RD AVE
PEORIA AZ
85381-5622
US

IV. Provider business mailing address

15396 N 83RD AVE
PEORIA AZ
85381-5622
US

V. Phone/Fax

Practice location:
  • Phone: 480-598-3439
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number
License Number State

VIII. Authorized Official

Name: KALYNN EGEA
Title or Position: OWNER
Credential: OD
Phone: 623-980-8671