Provider Demographics
NPI:1942221221
Name:SOLDOTNA OPTOMETRY CLINIC, LLC
Entity Type:Organization
Organization Name:SOLDOTNA OPTOMETRY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEMSKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:907-262-3168
Mailing Address - Street 1:155 SMITH WAY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-8060
Mailing Address - Country:US
Mailing Address - Phone:907-262-3168
Mailing Address - Fax:907-262-5458
Practice Address - Street 1:155 SMITH WAY
Practice Address - Street 2:SUITE 202
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-8060
Practice Address - Country:US
Practice Address - Phone:907-262-3168
Practice Address - Fax:907-262-5458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK#87152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK160643Medicare PIN
5712830001Medicare NSC