1366579468 NPI number — PACIFIC EYE CENTER

Table of content: (NPI 1366579468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366579468 NPI number — PACIFIC EYE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC EYE 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:
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:
1366579468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
562 HARMON LOOP RD
Provider Second Line Business Mailing Address:
STE D2
Provider Business Mailing Address City Name:
DEDEDO
Provider Business Mailing Address State Name:
GU
Provider Business Mailing Address Postal Code:
96929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
671-637-9889
Provider Business Mailing Address Fax Number:
671-632-5558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
562 HARMON LOOP RD
Provider Second Line Business Practice Location Address:
STE D2
Provider Business Practice Location Address City Name:
DEDEDO
Provider Business Practice Location Address State Name:
GU
Provider Business Practice Location Address Postal Code:
96929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
671-637-9889
Provider Business Practice Location Address Fax Number:
671-632-5558
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DIZON
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
MENDOZA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
671-637-9889

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OL026 , registered in the state of GU ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D3816501 , issued by the state of ( GU ) . This identifiers is of the category "MEDICAID".




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