1255406690 NPI number — LARRY R FABIAN & JEFFREY M FANELLI PTRS WESTSIDE FAMILY VISION CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255406690 NPI number — LARRY R FABIAN & JEFFREY M FANELLI PTRS WESTSIDE FAMILY VISION CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARRY R FABIAN & JEFFREY M FANELLI PTRS WESTSIDE FAMILY VISION CENTER
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:
1255406690
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1817 HAMILTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95125-5624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-264-1555
Provider Business Mailing Address Fax Number:
408-264-1562

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18780 COX AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARATOGA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95070-4109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-370-7303
Provider Business Practice Location Address Fax Number:
408-370-7405
Provider Enumeration Date:
11/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LE
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
Authorized Official Title or Position:
OPTICIAN
Authorized Official Telephone Number:
408-370-7303

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  BOL2584 , 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)





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