Provider Demographics
NPI:1437120334
Name:PRESCOTT EYE CARE & SURGICAL CENTER PC
Entity Type:Organization
Organization Name:PRESCOTT EYE CARE & SURGICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:WORTHEN
Authorized Official - Last Name:MORTENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-445-1234
Mailing Address - Street 1:3192 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-6610
Mailing Address - Country:US
Mailing Address - Phone:928-778-3950
Mailing Address - Fax:928-778-3999
Practice Address - Street 1:3192 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-6610
Practice Address - Country:US
Practice Address - Phone:928-778-3950
Practice Address - Fax:928-778-3999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ3C0001209Medicare PIN