MEDICARE: FAMILY FIRST VISION CARE ARIZONA PLLC

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

General Provider Information

NPI Number	:	1639875826
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY FIRST VISION CARE ARIZONA PLLC

Provider Business Mailing Address
First Line	:	PO BOX 631665
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-1665
Country	:	US
Telephone Number	:	614-831-0268
Fax Number	:

Provider Business Practice Location Address
First Line	:	2730 W DOVE VALLEY RD STE 120
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85085-5253
Country	:	US
Telephone Number	:	614-831-0268
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	NICOLE JANDERNAL
Credential	:
Telephone Number	:	732-236-7067

Provider Enumeration Date	:	01/31/2023
Last Update Date	:	04/28/2023

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