Provider Demographics
NPI:1881839405
Name:EYE GALLERY INC
Entity Type:Organization
Organization Name:EYE GALLERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:808-875-4466
Mailing Address - Street 1:380 HUKU LII PL
Mailing Address - Street 2:SUITE 107
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-7043
Mailing Address - Country:US
Mailing Address - Phone:808-875-4466
Mailing Address - Fax:808-874-3899
Practice Address - Street 1:380 HUKU LII PL
Practice Address - Street 2:SUITE 107
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-7043
Practice Address - Country:US
Practice Address - Phone:808-875-4466
Practice Address - Fax:808-874-3899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI644152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIBK017Medicare PIN