Provider Demographics
NPI:1962943118
Name:SPECTRA EYE INSTITUTE, LLC
Entity type:Organization
Organization Name:SPECTRA EYE INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AMATOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-583-2020
Mailing Address - Street 1:15401 N 29TH AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-4000
Mailing Address - Country:US
Mailing Address - Phone:623-583-2020
Mailing Address - Fax:623-583-2075
Practice Address - Street 1:15401 N 29TH AVE
Practice Address - Street 2:201
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-4001
Practice Address - Country:US
Practice Address - Phone:623-583-2020
Practice Address - Fax:623-583-2513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-20
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ544256OtherAHCCCS