1497866545 NPI number — THREE RIVERS OPTOMETRIC GRP INC

Table of content: (NPI 1497866545)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497866545 NPI number — THREE RIVERS OPTOMETRIC GRP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THREE RIVERS OPTOMETRIC GRP INC
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:
1497866545
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1245 THARP RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YUBA CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95993
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-674-5273
Provider Business Mailing Address Fax Number:
530-674-5275

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1245 THARP RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YUBA CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95993
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-674-5273
Provider Business Practice Location Address Fax Number:
530-674-5275
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TAXERA
Authorized Official First Name:
GARY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
530-674-5273

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  7072T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 7125T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 12712T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: COR949 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GSD004280 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4598980001 . This is a "MEDICARE CIGNA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ078052 . This is a "BS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CK6935 . This is a "RAILROAD MCARE" identifier . This identifiers is of the category "OTHER".




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