Healthcare Provider Details

I. General information

NPI: 1871702605
Provider Name (Legal Business Name): EYEDENTITY EYE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10170 W TROPICANA AVE SUITE # 153
LAS VEGAS NV
89147-8465
US

IV. Provider business mailing address

10170 W TROPICANA AVE SUITE # 153
LAS VEGAS NV
89147-8465
US

V. Phone/Fax

Practice location:
  • Phone: 702-873-2121
  • Fax: 702-873-2109
Mailing address:
  • Phone: 702-873-2121
  • Fax: 702-873-2109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number326
License Number StateNV

VIII. Authorized Official

Name: MRS. LAURA HOLT-MALONEY
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 702-873-2121