Provider Demographics
NPI:1043477847
Name:KOKOPELLI EYE CARE OPTICAL DEPT
Entity Type:Organization
Organization Name:KOKOPELLI EYE CARE OPTICAL DEPT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-775-5606
Mailing Address - Street 1:2820 N GLASSFORD HILL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-1242
Mailing Address - Country:US
Mailing Address - Phone:928-775-5606
Mailing Address - Fax:928-772-4999
Practice Address - Street 1:2820 N GLASSFORD HILL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-1242
Practice Address - Country:US
Practice Address - Phone:928-775-5606
Practice Address - Fax:928-772-4999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ26357156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty