Provider Demographics
NPI:1457569121
Name:LAKE HAVASU FAMILY EYECARE, LLC
Entity Type:Organization
Organization Name:LAKE HAVASU FAMILY EYECARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TANIA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:SOBCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:928-855-5026
Mailing Address - Street 1:2277 SWANSON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5991
Mailing Address - Country:US
Mailing Address - Phone:928-855-5026
Mailing Address - Fax:928-854-4512
Practice Address - Street 1:2277 SWANSON AVE STE 100
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5991
Practice Address - Country:US
Practice Address - Phone:928-855-5026
Practice Address - Fax:928-854-4512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1311152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5398210001Medicare NSC
AZZ102740Medicare ID - Type Unspecified