MEDICARE: EYECARE EXCELLENCE A PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	00070	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437158375
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYECARE EXCELLENCE A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	3450 E REZANOF DR
Second Line	:
City	:	KODIAK
State	:	AK
Zip	:	99615-6953
Country	:	US
Telephone Number	:	907-486-5504
Fax Number	:	907-486-6577

Provider Business Practice Location Address
First Line	:	3450 E. REZANOF DR.
Second Line	:
City	:	KODIAK
State	:	AK
Zip	:	99615-0827
Country	:	US
Telephone Number	:	907-486-5504
Fax Number	:	907-486-6577

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DESIREE WHEELER
Credential	:	OD
Telephone Number	:	907-486-5504

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	01/13/2021

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Directions to “EYECARE EXCELLENCE A PROFESSIONAL CORPORATION ” Practice Location

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