Healthcare Provider Details

I. General information

NPI: 1790310811
Provider Name (Legal Business Name): YAVAPAI OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7763 E FLORENTINE RD
PRESCOTT VALLEY AZ
86314-2289
US

IV. Provider business mailing address

7763 E FLORENTINE RD
PRESCOTT VALLEY AZ
86314-2289
US

V. Phone/Fax

Practice location:
  • Phone: 928-775-9393
  • Fax: 928-772-1279
Mailing address:
  • Phone: 928-775-9393
  • Fax: 928-772-1279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: JARED G SMEDLEY
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 928-775-9393