Healthcare Provider Details

I. General information

NPI: 1710417514
Provider Name (Legal Business Name): FAMILY FIRST VISION CARE ARIZONA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21001 N TATUM BLVD STE 18
PHOENIX AZ
85050-4207
US

IV. Provider business mailing address

4680 PARKWAY DR STE 22
MASON OH
45040-8296
US

V. Phone/Fax

Practice location:
  • Phone: 480-513-4184
  • Fax: 480-513-4184
Mailing address:
  • Phone: 513-445-9064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: NICOLE JANDERNAL
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 732-236-7067