1073620415 NPI number — NORTH BAY EYE ASSOCIATES A MEDICAL CORPORATION

Table of content: (NPI 1073620415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073620415 NPI number — NORTH BAY EYE ASSOCIATES A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH BAY EYE ASSOCIATES A MEDICAL 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:
NORTH BAY EYE ASSOCIATES ASC
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:
1073620415
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11688
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95406-1688
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-588-7939
Provider Business Mailing Address Fax Number:
707-544-0808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
380 TESCONI CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95401-4653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-544-3375
Provider Business Practice Location Address Fax Number:
707-544-0808
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRESLIN
Authorized Official First Name:
KIMBERLEE
Authorized Official Middle Name:
K
Authorized Official Title or Position:
ACCOUNTS RECEIVABLE MANAGER
Authorized Official Telephone Number:
707-588-7946

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  110000297 , 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: 110000297 . This is a "LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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