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General NPI Number Information
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NPI Number | 1538564984
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Entity Type | Organization
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Legal Business Name | EYE SHOP PLLC
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Dates
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Enumeration Date | 10/28/2014
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Last Update Date | 06/07/2020
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Provider Practice Location Address
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Address Line | 21321 E OCOTILLO RD STE 105
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City | QUEEN CREEK
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State | AZ
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Zip | 85142-5993
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Country | US
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Telephone | 480-656-7739
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Fax | 480-656-1637
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Provider Business Mailing Address
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Address Line | 21321 E OCOTILLO RD STE 105
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City | QUEEN CREEK
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State | AZ
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Zip | 85142-5993
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Country | US
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Telephone | 480-656-7739
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Fax | 480-656-1637
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DR. JARED A SHAVER
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Credential | OD
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Telephone | 480-656-7739
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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 | 1706
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License Number State | AZ
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