1467558361 NPI number — PACIFIC CHILDRENS EYECARE MEDICAL GROUP

Table of content: (NPI 1467558361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467558361 NPI number — PACIFIC CHILDRENS EYECARE MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC CHILDRENS EYECARE MEDICAL GROUP
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:
1467558361
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5528 PACHECO BLVD
Provider Second Line Business Mailing Address:
BUILDING A
Provider Business Mailing Address City Name:
PACHECO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94553-5126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-363-8170
Provider Business Mailing Address Fax Number:
925-363-4995

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1517 NORTH POINT ST.
Provider Second Line Business Practice Location Address:
#471
Provider Business Practice Location Address City Name:
SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-923-3926
Provider Business Practice Location Address Fax Number:
415-276-3783
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PAUL
Authorized Official First Name:
THEODORE
Authorized Official Middle Name:
OTIS
Authorized Official Title or Position:
OWENER
Authorized Official Telephone Number:
925-363-8170

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  A22914 , 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)





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