Provider Demographics
NPI:1891097150
Name:DESERT VISION AND EYE CARE, LLC
Entity Type:Organization
Organization Name:DESERT VISION AND EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZZULLA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:702-631-2015
Mailing Address - Street 1:8724 AZURE SKY DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-2223
Mailing Address - Country:US
Mailing Address - Phone:702-631-2015
Mailing Address - Fax:702-631-2511
Practice Address - Street 1:4116 W CRAIG RD STE 104
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-2733
Practice Address - Country:US
Practice Address - Phone:702-631-2015
Practice Address - Fax:702-631-2511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-18
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0231152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1194777219OtherINDIVIDUAL NPI
NV0231Medicaid
NVDX280ZMedicare PIN
NV0231Medicaid