1063603710 NPI number — MR. MANUEL ACEVEDO OPTICIAN

Table of content: MR. MANUEL ACEVEDO OPTICIAN (NPI 1063603710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063603710 NPI number — MR. MANUEL ACEVEDO OPTICIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ACEVEDO
Provider First Name:
MANUEL
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OPTICIAN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OPTICAL
Provider Other First Name:
ILLUSION
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1063603710
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 PALM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANGER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93657-4109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-875-4237
Provider Business Mailing Address Fax Number:
559-876-2300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
632 O ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANGER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93657-2417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-875-4237
Provider Business Practice Location Address Fax Number:
559-876-2300
Provider Enumeration Date:
08/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , with the licence number:  D 7230 , 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)





Copyright © 2007-2025 www.npivalidator.com