Healthcare Provider Details

I. General information

NPI: 1316186737
Provider Name (Legal Business Name): EYE CLINIC,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2009
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9151 ESTATE THOMAS FOOTHILLS PROFESSIONAL BLD#107
ST. THOMAS VI
00802
US

IV. Provider business mailing address

PO BOX 302682
ST. THOMAS VI
00803
US

V. Phone/Fax

Practice location:
  • Phone: 340-774-1531
  • Fax: 340-774-1517
Mailing address:
  • Phone: 340-774-1531
  • Fax: 340-774-1517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberVI1290
License Number StateVI

VIII. Authorized Official

Name: DR. KIDANE H ASSEFA
Title or Position: OWNER
Credential: MD
Phone: 340-774-1531