1518061159 NPI number — LARRY R FABIAN & JEFFREY M FANNELLI PTRS WESTSIDE FAMILY VISION CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518061159 NPI number — LARRY R FABIAN & JEFFREY M FANNELLI PTRS WESTSIDE FAMILY VISION CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARRY R FABIAN & JEFFREY M FANNELLI PTRS WESTSIDE FAMILY VISION CENTER
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:
6
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:
1518061159
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1817 HAMILTON AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95125-5624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-264-1555
Provider Business Mailing Address Fax Number:
408-264-1562

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1817 HAMILTON AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN JOSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95125-5624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-264-1555
Provider Business Practice Location Address Fax Number:
408-264-1562
Provider Enumeration Date:
09/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FANELLI
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
MARTIN
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
408-264-1555

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 410044714 . This is a "RAILROAD M/C - FANELLI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0518290001 . This is a "MEDICARE SUPPLIER NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 410044713 . This is a "RAILROAD M/C - FABIAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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