1548339112 NPI number — MANTECA OPTOMETRY

Table of content: (NPI 1548339112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548339112 NPI number — MANTECA OPTOMETRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANTECA 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:
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:
1548339112
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:
1532 BENNINGTON CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95209-4556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-477-3888
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
158 N MAPLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANTECA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95336-4503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-239-3504
Provider Business Practice Location Address Fax Number:
209-239-0741
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
LEANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
209-239-3504

Provider Taxonomy Codes

  • Taxonomy code: 152WP0200X , with the licence number:  12388T , 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: 1982704979 . This is a "MY NPI NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com