Provider Demographics
NPI:1942521695
Name:PROFESSIONAL EYECARE ASSOCIATES, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL EYECARE ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:O.D./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:D
Authorized Official - Last Name:JEFFERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:520-316-5590
Mailing Address - Street 1:545 N. PEART ROAD
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122
Mailing Address - Country:US
Mailing Address - Phone:520-316-5590
Mailing Address - Fax:520-316-5593
Practice Address - Street 1:545 N. PEART ROAD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122
Practice Address - Country:US
Practice Address - Phone:520-316-5590
Practice Address - Fax:520-316-5593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ940152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU65113Medicare UPIN