1346576295 NPI number — EYECENTER OPTOMETRICS, A PROFESSIONAL CORPORATION

Table of content: (NPI 1346576295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346576295 NPI number — EYECENTER OPTOMETRICS, A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYECENTER OPTOMETRICS, A PROFESSIONAL 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:
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:
1346576295
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5959 GREENBACK LN
Provider Second Line Business Mailing Address:
SUITE # 130
Provider Business Mailing Address City Name:
CITRUS HEIGHTS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95621-9562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-852-1600
Provider Business Mailing Address Fax Number:
916-852-0231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 SUNRISE BLVD
Provider Second Line Business Practice Location Address:
SUITE #120
Provider Business Practice Location Address City Name:
GOLD RIVER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95670-4374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-852-1600
Provider Business Practice Location Address Fax Number:
916-852-0231
Provider Enumeration Date:
10/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
LORI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
COMMUNICATIONS DIRECTOR
Authorized Official Telephone Number:
916-726-1818

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  BOL6465 , 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: ZZZ50558Z . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: GSD001121 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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