Provider Demographics
NPI:1669802013
Name:EYE BOUTIQUE OF SEDONA, PLLC
Entity type:Organization
Organization Name:EYE BOUTIQUE OF SEDONA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:JEANNE MARTIN
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:928-301-0457
Mailing Address - Street 1:80 HIGH VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86351-6961
Mailing Address - Country:US
Mailing Address - Phone:928-301-0457
Mailing Address - Fax:
Practice Address - Street 1:100 VERDE VALLEY SCHOOL RD
Practice Address - Street 2:SUITE 114
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86351-9053
Practice Address - Country:US
Practice Address - Phone:928-239-9901
Practice Address - Fax:928-239-9902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1467152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ612863Medicaid
1255304754OtherINDIVIDUAL NPI
1255304754OtherINDIVIDUAL NPI