Provider Demographics
NPI:1487084612
Name:AYESHA KIDD SENIOR EYECARE SERVICE LLC
Entity type:Organization
Organization Name:AYESHA KIDD SENIOR EYECARE SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AYESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-835-5024
Mailing Address - Street 1:5700 GRELOT RD
Mailing Address - Street 2:APT # 925
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-3617
Mailing Address - Country:US
Mailing Address - Phone:205-835-5024
Mailing Address - Fax:
Practice Address - Street 1:5700 GRELOT RD
Practice Address - Street 2:APT # 925
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-3617
Practice Address - Country:US
Practice Address - Phone:205-835-5024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-26
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-C61-TA-904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty