Provider Demographics
NPI:1508222399
Name:IDENICA EYECARE, LLC
Entity Type:Organization
Organization Name:IDENICA EYECARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LATESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:205-260-9579
Mailing Address - Street 1:1007 RED FARMER DR
Mailing Address - Street 2:
Mailing Address - City:HUEYTOWN
Mailing Address - State:AL
Mailing Address - Zip Code:35023-1886
Mailing Address - Country:US
Mailing Address - Phone:205-260-9579
Mailing Address - Fax:
Practice Address - Street 1:1007 RED FARMER DR
Practice Address - Street 2:
Practice Address - City:HUEYTOWN
Practice Address - State:AL
Practice Address - Zip Code:35023-1886
Practice Address - Country:US
Practice Address - Phone:205-260-9579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-D06-TA-966152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty