1508143827 NPI number — IMPERIAL VALLEY OPTOMTRIC CORPORATION

Table of content: (NPI 1508143827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508143827 NPI number — IMPERIAL VALLEY OPTOMTRIC CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMPERIAL VALLEY OPTOMTRIC 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:
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:
1508143827
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3451 S DOGWOOD AVE
Provider Second Line Business Mailing Address:
STE 1334
Provider Business Mailing Address City Name:
EL CENTRO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92243
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-768-9484
Provider Business Mailing Address Fax Number:
888-210-5799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1113 IMPERIAL AVE. W.
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
CALEXICO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-336-3003
Provider Business Practice Location Address Fax Number:
888-210-5799
Provider Enumeration Date:
11/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
TAM
Authorized Official First Name:
MAY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
760-336-3003

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GSD005600 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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