MEDICARE: EAGLE RIVER VISION CLINIC INC

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	332B00000X	Durable Medical Equipment & Medical Supplies	310247	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	30000001SWGYEAS	OTHER		CMS EHR CERTIFICATAION ID

General Provider Information

NPI Number	:	1558301945
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLE RIVER VISION CLINIC INC

Provider Business Mailing Address
First Line	:	16331 HERITAGE PL
Second Line	:	SUITE 104
City	:	EAGLE RIVER
State	:	AK
Zip	:	99577-7714
Country	:	US
Telephone Number	:	907-694-2511
Fax Number	:	907-694-3900

Provider Business Practice Location Address
First Line	:	16331 HERITAGE PL
Second Line	:	SUITE 104
City	:	EAGLE RIVER
State	:	AK
Zip	:	99577-7714
Country	:	US
Telephone Number	:	907-694-2511
Fax Number	:	907-694-3900

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT JAY FLECKENSTEIN
Credential	:	OD
Telephone Number	:	907-694-2511

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	02/07/2013

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Directions to “EAGLE RIVER VISION CLINIC INC ” Practice Location

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