1548202864 NPI number — ANTELOPE VALLEY OPTOMETRIC CENTER, INC.

Table of content: SARAH MARGARET POTTER (NPI 1730795089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548202864 NPI number — ANTELOPE VALLEY OPTOMETRIC CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANTELOPE VALLEY OPTOMETRIC CENTER, INC.
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:
1548202864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1745 W AVENUE K
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93534-6501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-942-8437
Provider Business Mailing Address Fax Number:
661-940-1959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1745 W AVENUE K
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93534-6501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-942-8437
Provider Business Practice Location Address Fax Number:
661-940-1959
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
661-942-8437

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  COR 486 , 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: ZZ40293Z . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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