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

Table of content: (NPI 1255406690)

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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