1225102874 NPI number — EYE CARE INSTITUTE, A MEDICAL CORPORATION

Table of content: (NPI 1225102874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225102874 NPI number — EYE CARE INSTITUTE, A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE CARE INSTITUTE, A MEDICAL CORPORATION
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:
EYE CARE INSTITUTE, OPTICAL DISPENSARY
Provider Other Organization Name Type Code:
5
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:
1225102874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
720 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95404-4421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-763-6400
Provider Business Mailing Address Fax Number:
707-528-4967

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1017 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95404-6608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-546-9800
Provider Business Practice Location Address Fax Number:
707-546-4112
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RICH
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
CORPORATION PRESIDENT
Authorized Official Telephone Number:
707-546-9800

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  0399240001 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ76363Z , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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