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General NPI Number Information
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NPI Number | 1669802013
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Entity Type | Organization
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Legal Business Name | EYE BOUTIQUE OF SEDONA, PLLC
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Dates
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Enumeration Date | 11/22/2013
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Last Update Date | 11/22/2013
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Provider Practice Location Address
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Address Line | 100 VERDE VALLEY SCHOOL RD SUITE 114
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City | SEDONA
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State | AZ
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Zip | 86351-9053
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Country | US
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Telephone | 928-239-9901
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Fax | 928-239-9902
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Provider Business Mailing Address
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Address Line | 80 HIGH VIEW DR
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City | SEDONA
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State | AZ
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Zip | 86351-6961
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Country | US
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Telephone | 928-301-0457
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | CAROLYN JEANNE MARTIN CHANG
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Credential | OD
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Telephone | 928-301-0457
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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 | 1467
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License Number State | AZ
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