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General NPI Number Information
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NPI Number | 1558301945
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Entity Type | Organization
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Legal Business Name | EAGLE RIVER VISION CLINIC INC
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Dates
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Enumeration Date | 06/07/2006
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Last Update Date | 02/07/2013
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Provider Practice Location Address
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Address Line | 16331 HERITAGE PL SUITE 104
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City | EAGLE RIVER
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State | AK
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Zip | 99577-7714
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Country | US
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Telephone | 907-694-2511
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Fax | 907-694-3900
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Provider Business Mailing Address
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Address Line | 16331 HERITAGE PL SUITE 104
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City | EAGLE RIVER
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State | AK
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Zip | 99577-7714
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Country | US
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Telephone | 907-694-2511
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Fax | 907-694-3900
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Authorized Official
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Title or Position | PRESIDENT
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Name | ROBERT JAY FLECKENSTEIN
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Credential | OD
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Telephone | 907-694-2511
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 310247
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License Number State | AK
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