Provider Demographics
NPI:1730478389
Name:AMANDA MISINCO, PLLC
Entity Type:Organization
Organization Name:AMANDA MISINCO, PLLC
Other - Org Name:OPTICAL INTUITIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MISINCO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:480-785-4804
Mailing Address - Street 1:2206 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-2245
Mailing Address - Country:US
Mailing Address - Phone:480-478-9562
Mailing Address - Fax:
Practice Address - Street 1:9855 S PRIEST DR
Practice Address - Street 2:SUITE 101
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-3605
Practice Address - Country:US
Practice Address - Phone:480-785-4804
Practice Address - Fax:480-940-1832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1686261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ144473Medicare PIN