Basic Information
| Provider Information | |||||||||
| NPI: | 1154461747 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ENVISION EYECARE CENTER PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 W WETMORE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857055094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202932363 | ||||||||
| FaxNumber: | 5202930475 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 W WETMORE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857055094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202932363 | ||||||||
| FaxNumber: | 5202930475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 12/13/2007 | ||||||||
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| AuthorizedOfficialLastName: | BARRY | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER, CEO | ||||||||
| AuthorizedOfficialTelephone: | 5202932363 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | AZ-013 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 867480 | 05 | AZ | MEDICAID | 5801810001 | 01 | AZ | DMEPOS-SUPPLIER NO. | OTHER |