Provider Demographics
NPI:1295938207
Name:FORNARA EYE CENTER P.C.
Entity type:Organization
Organization Name:FORNARA EYE CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:K
Authorized Official - Last Name:FORNARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-634-2883
Mailing Address - Street 1:199 S. CANDY LN
Mailing Address - Street 2:2A
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326
Mailing Address - Country:US
Mailing Address - Phone:928-634-2883
Mailing Address - Fax:928-634-0110
Practice Address - Street 1:199 S CANDY LN
Practice Address - Street 2:2A
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4183
Practice Address - Country:US
Practice Address - Phone:928-634-2883
Practice Address - Fax:928-634-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZT41609Medicare UPIN
AZ0748450001Medicare NSC
AZZ0000PFDGHMedicare PIN