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General NPI Number Information
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NPI Number | 1295100204
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Entity Type | Organization
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Legal Business Name | ACTIVE EYECARE LLC
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Dates
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Enumeration Date | 12/02/2015
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Last Update Date | 12/02/2015
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Provider Practice Location Address
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Address Line | 16968 W BELL RD SUITE 402
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City | SURPRISE
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State | AZ
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Zip | 85374-8943
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Country | US
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Telephone | 623-214-0353
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Fax | 623-214-0693
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Provider Business Mailing Address
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Address Line | 16968 W BELL RD SUITE 402
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City | SURPRISE
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State | AZ
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Zip | 85374-8943
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Country | US
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Telephone | 623-214-0353
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Fax | 623-214-0693
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARK EDWARD FECHTEL
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Credential | OD
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Telephone | 623-214-0353
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 1117
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License Number State | AZ
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