Provider Demographics
NPI:1295238061
Name:SORENSON, REBECCA RAE (OD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:RAE
Last Name:SORENSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4036
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503-4036
Mailing Address - Country:US
Mailing Address - Phone:218-343-7684
Mailing Address - Fax:
Practice Address - Street 1:PO BOX PH
Practice Address - Street 2:
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503
Practice Address - Country:US
Practice Address - Phone:928-674-7628
Practice Address - Fax:928-674-7707
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-17
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0004000152W00000X
OK3041152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist