1144313412 NPI number — JOHN CELIS, O.D., A PROFESSIONAL CORPORATION

Table of content: (NPI 1144313412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144313412 NPI number — JOHN CELIS, O.D., A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN CELIS, O.D., A PROFESSIONAL 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:
LAKE FOREST FAMILY EYECARE
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:
1144313412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23600 ROCKFIELD BLVD
Provider Second Line Business Mailing Address:
SUITE 3F
Provider Business Mailing Address City Name:
LAKE FOREST
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92630-1624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-206-1560
Provider Business Mailing Address Fax Number:
949-206-1655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23600 ROCKFIELD BLVD
Provider Second Line Business Practice Location Address:
SUITE 3F
Provider Business Practice Location Address City Name:
LAKE FOREST
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92630-1624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-206-1560
Provider Business Practice Location Address Fax Number:
949-206-1655
Provider Enumeration Date:
10/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CELIS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
DEGUZMAN
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
949-206-1560

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  11704T , 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: 2462134 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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