1386702553 NPI number — RALPH E SCHROCK OPTOMETRIC CORPORATION

Table of content: (NPI 1386702553)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386702553 NPI number — RALPH E SCHROCK OPTOMETRIC CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RALPH E SCHROCK OPTOMETRIC CORPORATION
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:
OPTOMETRIC VISION DEVELOPMENT CENTER
Provider Other Organization Name Type Code:
3
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:
1386702553
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8950 VILLA LA JOLLA DRIVE
Provider Second Line Business Mailing Address:
B128
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-1705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-453-0442
Provider Business Mailing Address Fax Number:
858-453-5291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8950 VILLA LA JOLLA DRIVE
Provider Second Line Business Practice Location Address:
B128
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-1705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-453-0442
Provider Business Practice Location Address Fax Number:
858-453-5291
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VALENTI
Authorized Official First Name:
CLAUDE
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
OWNER OPTOMETRIST
Authorized Official Telephone Number:
858-453-0442

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  7608 , 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: W0P7608A . This is a "MEDICARE PPIN PROVIDER GR" identifier . This identifiers is of the category "OTHER".




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