Healthcare Provider Details

I. General information

NPI: 1487822201
Provider Name (Legal Business Name): EYEZONE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 KINGSBURY GRADE SUITE 103
STATELINE NV
89449-7170
US

IV. Provider business mailing address

PO BOX 7170
STATELINE NV
89449-7170
US

V. Phone/Fax

Practice location:
  • Phone: 775-588-3500
  • Fax: 775-588-6045
Mailing address:
  • Phone: 775-588-3500
  • Fax: 775-588-6045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number278
License Number StateNV

VIII. Authorized Official

Name: DR. MARK MICHITSCH
Title or Position: OWNER
Credential: OPTOMETRIST
Phone: 775-588-3500