Healthcare Provider Details

I. General information

NPI: 1477166379
Provider Name (Legal Business Name): PRIMARY EYE CARE CENTER OF AHWATUKEE, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16515 S 40TH ST STE 111
PHOENIX AZ
85048-0559
US

IV. Provider business mailing address

3107 E SOUTH FORK DR
PHOENIX AZ
85048-8753
US

V. Phone/Fax

Practice location:
  • Phone: 480-706-2020
  • Fax:
Mailing address:
  • Phone: 480-330-5081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL DE RUBEIS
Title or Position: CEO
Credential: OD
Phone: 480-706-2020