Healthcare Provider Details

I. General information

NPI: 1740431378
Provider Name (Legal Business Name): PRESCOTT EYE CARE & SURGICAL CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3769 CROSSING DRIVE
PRESCOTT AZ
86305-1606
US

IV. Provider business mailing address

3192 WILLOW CREEK RD
PRESCOTT AZ
86301-6610
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-9200
  • Fax: 928-772-8107
Mailing address:
  • Phone: 928-445-1234
  • Fax: 928-772-8107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1100X
TaxonomyOphthalmic Technician/Technologist
License Number
License Number State

VIII. Authorized Official

Name: STEVEN W. MORTENSON
Title or Position: CEO
Credential: MD
Phone: 928-445-9200