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General NPI Number Information
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NPI Number | 1477763498
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Entity Type | Organization
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Legal Business Name | ELITE OPTICAL, LLC
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Dates
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Enumeration Date | 05/22/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1635 N GREENFIELD RD SUITE 136
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City | MESA
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State | AZ
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Zip | 85205-4005
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Country | US
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Telephone | 480-219-2412
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Fax | 480-219-2843
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Provider Business Mailing Address
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Address Line | 1635 N GREENFIELD RD SUITE 136
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City | MESA
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State | AZ
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Zip | 85205-4005
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Country | US
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Telephone | 480-219-2412
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Fax | 480-219-2843
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DOUGLAS CHARLES MINER
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Credential | O.D.
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Telephone | 480-219-2412
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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 | 641
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License Number State | AZ
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