Provider Demographics
NPI:1114140019
Name:KOKOPELLI EYE CARE PC
Entity Type:Organization
Organization Name:KOKOPELLI EYE CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-771-9000
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 1:412 WHIPPLE ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1712
Practice Address - Country:US
Practice Address - Phone:928-771-9000
Practice Address - Fax:928-771-9460
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KOKOPELLI EYE CARE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-10
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOSC3634261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ110504Medicare PIN