Provider Demographics
NPI:1942446083
Name:MOULTON FAMILY EYE CARE LLC
Entity Type:Organization
Organization Name:MOULTON FAMILY EYE CARE LLC
Other - Org Name:DBA IMAGE EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:HUGH
Authorized Official - Last Name:MOULTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:480-380-5116
Mailing Address - Street 1:1075 S IDAHO RD
Mailing Address - Street 2:SUITE 105B
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85119-6496
Mailing Address - Country:US
Mailing Address - Phone:480-380-5116
Mailing Address - Fax:480-380-0791
Practice Address - Street 1:1075 S IDAHO RD
Practice Address - Street 2:SUITE 105B
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85119-6496
Practice Address - Country:US
Practice Address - Phone:480-380-5116
Practice Address - Fax:480-380-0791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-19
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1452152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZV06108Medicare UPIN
AZDU1181Medicare PIN
AZZ128953Medicare PIN