Provider Demographics
NPI:1922205061
Name:MAVENCAMP FAMILY EYECARE, INC
Entity Type:Organization
Organization Name:MAVENCAMP FAMILY EYECARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAVENCAMP
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:907-479-4700
Mailing Address - Street 1:570 RIVERSTONE WAY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-2939
Mailing Address - Country:US
Mailing Address - Phone:907-479-4700
Mailing Address - Fax:907-457-5596
Practice Address - Street 1:570 RIVERSTONE WAY
Practice Address - Street 2:SUITE 3
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-2939
Practice Address - Country:US
Practice Address - Phone:907-479-4700
Practice Address - Fax:907-457-5596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKA240152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKVO7087Medicare UPIN