1609247279 NPI number — PRIME OPTICAL

Table of content: (NPI 1609247279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609247279 NPI number — PRIME OPTICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME OPTICAL
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:
1609247279
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
407 E GILBERT ST
Provider Second Line Business Mailing Address:
SUITE # 10
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92404-5325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-888-8700
Provider Business Mailing Address Fax Number:
909-888-8710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
407 E GILBERT ST
Provider Second Line Business Practice Location Address:
SUITE # 10
Provider Business Practice Location Address City Name:
SAN BERNARDINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92404-5325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-888-8700
Provider Business Practice Location Address Fax Number:
909-888-8710
Provider Enumeration Date:
10/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SALCEDO
Authorized Official First Name:
MARIANO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/OPTICIAN
Authorized Official Telephone Number:
909-888-8700

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  SL40434 , 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: 8005541312 . This is a "EIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com