Provider Demographics
NPI:1477763498
Name:ELITE OPTICAL, LLC
Entity Type:Organization
Organization Name:ELITE OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:MINER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:480-219-2412
Mailing Address - Street 1:1635 N GREENFIELD RD
Mailing Address - Street 2:SUITE 136
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-4005
Mailing Address - Country:US
Mailing Address - Phone:480-219-2412
Mailing Address - Fax:480-219-2843
Practice Address - Street 1:1635 N GREENFIELD RD
Practice Address - Street 2:SUITE 136
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4005
Practice Address - Country:US
Practice Address - Phone:480-219-2412
Practice Address - Fax:480-219-2843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ641152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty