=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861243537
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIERRA VISTA EYECARE P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2024
-----------------------------------------------------
Last Update Date | 03/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 STATE HWY 90, INSIDE WALMART VISION CTR
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-843-1007
-----------------------------------------------------
Fax | 520-439-4929
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3417 HERBA DE MARIA
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-843-1007
-----------------------------------------------------
Fax | 520-439-4929
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST / OWNER
-----------------------------------------------------
Name | DR. YVONNE DENISE LEE
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 520-843-1007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------