=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457410623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABC CHILDREN'S EYE SPECIALISTS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 09/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14418 W MEEKER BLVD STE 101
-----------------------------------------------------
City | SUN CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85375-5290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-222-2234
-----------------------------------------------------
Fax | 866-985-7247
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 97876
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-222-2234
-----------------------------------------------------
Fax | 602-222-3025
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP PRACTICE DEVELOPMENT
-----------------------------------------------------
Name | DANIEL REITZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-222-2234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------