1255590238 NPI number — LAGUNA CREEK OPTOMETRY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255590238 NPI number — LAGUNA CREEK OPTOMETRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAGUNA CREEK OPTOMETRY
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:
DRS. CHIN & CHIN, O.D.S
Provider Other Organization Name Type Code:
5
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:
1255590238
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5050 LAGUNA BLVD
Provider Second Line Business Mailing Address:
#113
Provider Business Mailing Address City Name:
ELK GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95758-4151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-684-7070
Provider Business Mailing Address Fax Number:
916-684-8048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5050 LAGUNA BLVD
Provider Second Line Business Practice Location Address:
#113
Provider Business Practice Location Address City Name:
ELK GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95758-4151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-684-7070
Provider Business Practice Location Address Fax Number:
916-684-8048
Provider Enumeration Date:
06/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CHIN
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
DARRELL
Authorized Official Title or Position:
OWNER/OPTOMETRIST
Authorized Official Telephone Number:
916-684-7070

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  8208T , 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: SD0082080 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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