1033131933 NPI number — PENINSULA EYECARE MEDICAL ASSOCIATES

Table of content: (NPI 1033131933)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033131933 NPI number — PENINSULA EYECARE MEDICAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENINSULA EYECARE MEDICAL ASSOCIATES
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:
1033131933
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 S PACIFIC AVE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN PEDRO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90731-3267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-547-9991
Provider Business Mailing Address Fax Number:
310-547-2389

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 S PACIFIC AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN PEDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90731-3267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-547-9991
Provider Business Practice Location Address Fax Number:
310-547-2389
Provider Enumeration Date:
07/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
JOEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-547-9991

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com