Healthcare Provider Details

I. General information

NPI: 1639723471
Provider Name (Legal Business Name): EYE CARE FOR KIDS ARIZONA CHAPTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6615 N 39TH AVE
PHOENIX AZ
85019-1334
US

IV. Provider business mailing address

6911 S STATE ST
MIDVALE UT
84047-1239
US

V. Phone/Fax

Practice location:
  • Phone: 801-285-5443
  • Fax:
Mailing address:
  • Phone: 801-285-5443
  • Fax: 801-255-8526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FC0800X
TaxonomyContact Lens Technician/Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code156FC0801X
TaxonomyContact Lens Fitter
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH G CARBONE
Title or Position: EXECUTIVE DIRECTOR
Credential: ABOC, NCLC
Phone: 801-285-5443