Provider Demographics
NPI:1427354422
Name:EBCON OPTICS LLC
Entity type:Organization
Organization Name:EBCON OPTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:BUENSUCESO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:623-980-5496
Mailing Address - Street 1:500 N ESTRELLA PKWY
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-4135
Mailing Address - Country:US
Mailing Address - Phone:623-980-5496
Mailing Address - Fax:
Practice Address - Street 1:500 N ESTRELLA PKWY
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-4135
Practice Address - Country:US
Practice Address - Phone:623-980-5496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1352152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ144592Medicare PIN
AZZ144593Medicare PIN
AZZ144591Medicare PIN