Provider Demographics
NPI:1023074291
Name:ARIZONA EYE INSTITUTE & COSMETIC LASER CENTER LLC
Entity type:Organization
Organization Name:ARIZONA EYE INSTITUTE & COSMETIC LASER CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EMILIO
Authorized Official - Middle Name:M
Authorized Official - Last Name:JUSTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-975-2020
Mailing Address - Street 1:19052 N R H JOHNSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-4401
Mailing Address - Country:US
Mailing Address - Phone:623-975-2020
Mailing Address - Fax:623-975-7005
Practice Address - Street 1:19052 N R H JOHNSON BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-4401
Practice Address - Country:US
Practice Address - Phone:623-975-2020
Practice Address - Fax:623-975-7005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOSC3384261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ74806Medicare PIN
AZP00038520Medicare PIN