Healthcare Provider Details

I. General information

NPI: 1558519363
Provider Name (Legal Business Name): JULIAN C ARCHER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 N MARINE CORPS DR STE 202
TAMUNING GU
96913-4307
US

IV. Provider business mailing address

736 ROUTE 4 STE 202
SINAJANA GU
96910-3368
US

V. Phone/Fax

Practice location:
  • Phone: 671-989-4747
  • Fax: 671-989-4743
Mailing address:
  • Phone: 671-989-4747
  • Fax: 671-989-4743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2672
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOL-047
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: