Provider Demographics
NPI:1558301945
Name:EAGLE RIVER VISION CLINIC INC
Entity Type:Organization
Organization Name:EAGLE RIVER VISION CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:FLECKENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:907-694-2511
Mailing Address - Street 1:16331 HERITAGE PL
Mailing Address - Street 2:SUITE 104
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7714
Mailing Address - Country:US
Mailing Address - Phone:907-694-2511
Mailing Address - Fax:907-694-3900
Practice Address - Street 1:16331 HERITAGE PL
Practice Address - Street 2:SUITE 104
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7714
Practice Address - Country:US
Practice Address - Phone:907-694-2511
Practice Address - Fax:907-694-3900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK310247332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
30000001SWGYEASOtherCMS EHR CERTIFICATAION ID
30000001SWGYEASOtherCMS EHR CERTIFICATAION ID