Healthcare Provider Details

I. General information

NPI: 1437120334
Provider Name (Legal Business Name): PRESCOTT EYE CARE & SURGICAL CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3192 WILLOW CREEK RD
PRESCOTT AZ
86301-6610
US

IV. Provider business mailing address

3192 WILLOW CREEK RD
PRESCOTT AZ
86301-6610
US

V. Phone/Fax

Practice location:
  • Phone: 928-778-3950
  • Fax: 928-778-3999
Mailing address:
  • Phone: 928-778-3950
  • Fax: 928-778-3999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. STEVEN WORTHEN MORTENSON
Title or Position: CEO/ MEDICAL DIRECTOR
Credential: M.D.
Phone: 928-445-1234