Provider Demographics
NPI:1043078561
Name:OPTIC GALLERY SKYE CANYON LLC
Entity Type:Organization
Organization Name:OPTIC GALLERY SKYE CANYON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FRILLARTE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:702-336-9349
Mailing Address - Street 1:7330 ORCHARD HARVEST AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-4819
Mailing Address - Country:US
Mailing Address - Phone:702-336-9349
Mailing Address - Fax:
Practice Address - Street 1:9560 W SKYE CANYON PARK DR STE 180
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89166-6795
Practice Address - Country:US
Practice Address - Phone:702-872-2020
Practice Address - Fax:702-443-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-08
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV106621Medicaid