Provider Demographics
NPI:1255483970
Name:KETCHIKAN EYE CARE CENTER, L.L.C.
Entity type:Organization
Organization Name:KETCHIKAN EYE CARE CENTER, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHRISTIANSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:907-225-2020
Mailing Address - Street 1:351 CARLANNA LAKE RD
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901
Mailing Address - Country:US
Mailing Address - Phone:907-225-2020
Mailing Address - Fax:907-247-1259
Practice Address - Street 1:351 CARLANNA LAKE RD
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901
Practice Address - Country:US
Practice Address - Phone:907-225-2020
Practice Address - Fax:907-247-2015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1297120001Medicare NSC
AKK151104Medicare PIN