Healthcare Provider Details

I. General information

NPI: 1225429673
Provider Name (Legal Business Name): NICOLEX LLC DBA MOON VALLEY EYECARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 02/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14435 N 7TH ST STE 104
PHOENIX AZ
85022-4378
US

IV. Provider business mailing address

14435 N 7TH ST STE 104
PHOENIX AZ
85022-4378
US

V. Phone/Fax

Practice location:
  • Phone: 602-993-2727
  • Fax:
Mailing address:
  • Phone: 602-993-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberAZ1210
License Number StateAZ

VIII. Authorized Official

Name: DR. JESSE DOMINGUEZ
Title or Position: OWNER
Credential: O.D.
Phone: 602-993-2727