Provider Demographics
NPI:1386224608
Name:PRISM EYE ASSOCIATES LLC
Entity Type:Organization
Organization Name:PRISM EYE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:PEDIGO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:907-891-7191
Mailing Address - Street 1:1200 GLACIER AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-1567
Mailing Address - Country:US
Mailing Address - Phone:907-885-3999
Mailing Address - Fax:
Practice Address - Street 1:1200 GLACIER AVE STE 103
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-1567
Practice Address - Country:US
Practice Address - Phone:907-885-3999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRISM EYE ASSOCIATES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-11
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty