1174651483 NPI number — FAMILY VISION CARE OPTOMETRY OF MODESTO

Table of content: KIANI AYALA (NPI 1639409691)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174651483 NPI number — FAMILY VISION CARE OPTOMETRY OF MODESTO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY VISION CARE OPTOMETRY OF MODESTO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174651483
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
817 COFFEE RD
Provider Second Line Business Mailing Address:
BUILDING D
Provider Business Mailing Address City Name:
MODESTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95355-4241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-524-9291
Provider Business Mailing Address Fax Number:
209-524-6362

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
817 COFFEE RD
Provider Second Line Business Practice Location Address:
BUILDING D
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95355-4241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-524-9291
Provider Business Practice Location Address Fax Number:
209-524-6362
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROSENOW
Authorized Official First Name:
ELDON
Authorized Official Middle Name:
LANG
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
209-524-9291

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4827220001 . This is a "DMERC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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