Provider Demographics
NPI:1689630832
Name:DESERT FAMILY EYE CENTER, P.C.
Entity Type:Organization
Organization Name:DESERT FAMILY EYE CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:CORBRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:928-757-5005
Mailing Address - Street 1:2187 AIRWAY AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3669
Mailing Address - Country:US
Mailing Address - Phone:928-757-5005
Mailing Address - Fax:928-757-9057
Practice Address - Street 1:2187 AIRWAY AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3669
Practice Address - Country:US
Practice Address - Phone:928-757-5005
Practice Address - Fax:928-757-9057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ829152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0677830001Medicare NSC
AZU37152Medicare UPIN
AZOD829Medicare ID - Type Unspecified