MEDICARE: DESERT VISION AND EYE CARE, LLC

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	0231	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1194777219	OTHER	NV	INDIVIDUAL NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891097150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESERT VISION AND EYE CARE, LLC

Provider Business Mailing Address
First Line	:	8724 AZURE SKY DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-2223
Country	:	US
Telephone Number	:	702-631-2015
Fax Number	:	702-631-2511

Provider Business Practice Location Address
First Line	:	4116 W CRAIG RD STE 104
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-2733
Country	:	US
Telephone Number	:	702-631-2015
Fax Number	:	702-631-2511

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DONALD MAZZULLA
Credential	:	O.D.
Telephone Number	:	702-631-2015

Provider Enumeration Date	:	11/18/2010
Last Update Date	:	08/27/2014

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