Provider Demographics
NPI:1295930410
Name:PREMIER EYECARE OF EDMOND PLLC
Entity type:Organization
Organization Name:PREMIER EYECARE OF EDMOND PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-513-8150
Mailing Address - Street 1:2841 NW 173RD ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-6728
Mailing Address - Country:US
Mailing Address - Phone:405-513-8150
Mailing Address - Fax:405-513-8153
Practice Address - Street 1:2841 NW 173RD STREET
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003
Practice Address - Country:US
Practice Address - Phone:405-513-8150
Practice Address - Fax:405-513-8153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2613152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200115110AMedicaid