Healthcare Provider Details

I. General information

NPI: 1194962175
Provider Name (Legal Business Name): EYE Q VISION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21001 N TATUM BLVD SUITE 18-1030
PHOENIX AZ
85050-4206
US

IV. Provider business mailing address

21001 N TATUM BLVD SUITE 18-1030
PHOENIX AZ
85050-4206
US

V. Phone/Fax

Practice location:
  • Phone: 480-513-4184
  • Fax:
Mailing address:
  • Phone: 480-513-4184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberAZ549
License Number StateAZ

VIII. Authorized Official

Name: DR. RANDALL CARL PAUL
Title or Position: EYE Q VISION MANAGER
Credential: O.D.
Phone: 480-513-4184