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General NPI Number Information
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NPI Number | 1285823062
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Entity Type | Organization
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Legal Business Name | KODIAK VISION CLINIC & SALLY'S EYELAND, INC.
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Dates
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Enumeration Date | 10/17/2007
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Last Update Date | 04/07/2017
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Provider Practice Location Address
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Address Line | 214 W REZANOF DR
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City | KODIAK
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State | AK
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Zip | 99615-6044
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Country | US
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Telephone | 907-486-6117
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Fax |
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Provider Business Mailing Address
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Address Line | 214 W REZANOF DR
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City | KODIAK
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State | AK
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Zip | 99615-6044
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Country | US
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Telephone | 907-486-6117
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Fax |
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Authorized Official
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Title or Position | OWNER/OPTOMETRIST
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Name | DR. JERIMIAH MYERS
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Credential | O.D.
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Telephone | 907-486-6117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | AAO102
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License Number State | AK
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