Healthcare Provider Details

I. General information

NPI: 1558449983
Provider Name (Legal Business Name): RENITA CHARLENE FROST OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7840 E ST ROUTE HWY 69 SUITE A-5A
PRESCOTT VALLEY AZ
86314-2274
US

IV. Provider business mailing address

616 N ZUNI TRL
DEWEY AZ
86327-5638
US

V. Phone/Fax

Practice location:
  • Phone: 928-775-9393
  • Fax:
Mailing address:
  • Phone: 928-533-2671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number521
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: