=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396527545
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETHANY ROYBAL LDO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2023
-----------------------------------------------------
Last Update Date | 04/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 755 S 20TH AVE
-----------------------------------------------------
City | SAFFORD
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85546-3322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-348-0105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 755 S 20TH AVE
-----------------------------------------------------
City | SAFFORD
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85546-3322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-348-0105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | LDO-3076
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------