Provider Demographics
NPI:1013502004
Name:ELYSIAN EYECARE PLLC
Entity Type:Organization
Organization Name:ELYSIAN EYECARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:PHUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:347-279-1020
Mailing Address - Street 1:1971 HIGHWAY 287 N STE 105
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8983
Mailing Address - Country:US
Mailing Address - Phone:817-453-7591
Mailing Address - Fax:
Practice Address - Street 1:1971 HIGHWAY 287 N STE 105
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-8983
Practice Address - Country:US
Practice Address - Phone:817-453-7591
Practice Address - Fax:817-453-7715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center