1245517804 NPI number — RUSSELL R SLAUGH OD AN OPTOMETRIC CORPORATION

Table of content: (NPI 1245517804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245517804 NPI number — RUSSELL R SLAUGH OD AN OPTOMETRIC CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUSSELL R SLAUGH OD AN OPTOMETRIC 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:
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:
1245517804
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
56970 YUCCA TRL
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
YUCCA VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92284-7910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-228-2020
Provider Business Mailing Address Fax Number:
760-369-2020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
56970 YUCCA TRL
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
YUCCA VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92284-7910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-228-2020
Provider Business Practice Location Address Fax Number:
760-369-2020
Provider Enumeration Date:
11/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SLAUGH
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
760-228-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  14240 , 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: 1245517804 . This is a "GROUP NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1659684751 . This is a "RUSSELL R SLAUGH O.D." identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1134103484 . This is a "DENNIS G. LOWMAN O.D." identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1770922395 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: ZZZ696612 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: SD0142400 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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