Provider Demographics
NPI:1154749653
Name:AGAPE PENINSULA EYE CARE, LLC
Entity type:Organization
Organization Name:AGAPE PENINSULA EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:K
Authorized Official - Last Name:HOLM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:907-252-2285
Mailing Address - Street 1:PO BOX 287
Mailing Address - Street 2:
Mailing Address - City:CLAM GULCH
Mailing Address - State:AK
Mailing Address - Zip Code:99568-0287
Mailing Address - Country:US
Mailing Address - Phone:907-252-2285
Mailing Address - Fax:888-623-2285
Practice Address - Street 1:55562 RAZOR CT
Practice Address - Street 2:
Practice Address - City:CLAM GULCH
Practice Address - State:AK
Practice Address - Zip Code:99568
Practice Address - Country:US
Practice Address - Phone:907-252-2285
Practice Address - Fax:888-623-2285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-01
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK334152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty