Provider Demographics
NPI:1710417514
Name:FAMILY FIRST VISION CARE ARIZONA PLLC
Entity Type:Organization
Organization Name:FAMILY FIRST VISION CARE ARIZONA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JANDERNAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-236-7067
Mailing Address - Street 1:4680 PARKWAY DR STE 22
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-8296
Mailing Address - Country:US
Mailing Address - Phone:513-445-9064
Mailing Address - Fax:
Practice Address - Street 1:21001 N TATUM BLVD STE 18
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4207
Practice Address - Country:US
Practice Address - Phone:480-513-4184
Practice Address - Fax:480-513-4184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-14
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty