1396160479 NPI number — JARED HAGAN OPTOMETRY

Table of content: (NPI 1396160479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396160479 NPI number — JARED HAGAN OPTOMETRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JARED HAGAN OPTOMETRY
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:
1396160479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7007 FRIARS RD STE 667A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92108-1148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-876-7456
Provider Business Mailing Address Fax Number:
888-723-8436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5929 MILDRED ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-1422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-876-7456
Provider Business Practice Location Address Fax Number:
888-723-8436
Provider Enumeration Date:
02/25/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HAGAN
Authorized Official First Name:
JARED
Authorized Official Middle Name:
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
858-876-7456

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT14385TLG , 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: OPT14385TLG . This is a "CALIFORNIA OPTOMETRY LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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