Provider Demographics
NPI:1407190598
Name:CAPELLA EYECARE
Entity Type:Organization
Organization Name:CAPELLA EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:HA
Authorized Official - Middle Name:ANH
Authorized Official - Last Name:PHAM-JIBBEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:480-656-2111
Mailing Address - Street 1:12625 N SAGUARO BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-4183
Mailing Address - Country:US
Mailing Address - Phone:480-656-2111
Mailing Address - Fax:480-621-8879
Practice Address - Street 1:12625 N SAGUARO BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-4183
Practice Address - Country:US
Practice Address - Phone:480-656-2111
Practice Address - Fax:480-621-8879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1466152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ161757Medicare PIN