Provider Demographics
NPI:1285823062
Name:KODIAK VISION CLINIC & SALLY'S EYELAND, INC.
Entity Type:Organization
Organization Name:KODIAK VISION CLINIC & SALLY'S EYELAND, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JERIMIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:907-486-6117
Mailing Address - Street 1:214 W REZANOF DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6044
Mailing Address - Country:US
Mailing Address - Phone:907-486-6117
Mailing Address - Fax:
Practice Address - Street 1:214 W REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6044
Practice Address - Country:US
Practice Address - Phone:907-486-6117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAAO102152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK152522Medicare PIN