1508691791 NPI number — PRUITT OPTOMETRIC EYE CARE LTD

Table of content: (NPI 1508691791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508691791 NPI number — PRUITT OPTOMETRIC EYE CARE LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRUITT OPTOMETRIC EYE CARE LTD
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:
1508691791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26025 NEWPORT RD.
Provider Second Line Business Mailing Address:
STE. F #455
Provider Business Mailing Address City Name:
MENIFEE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92584-7309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-395-7585
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26025 NEWPORT RD.
Provider Second Line Business Practice Location Address:
STE. F #455
Provider Business Practice Location Address City Name:
MENIFEE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92584-7309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-395-7585
Provider Business Practice Location Address Fax Number:
651-395-7585
Provider Enumeration Date:
09/05/2024

Additional Information

Authorized Official

Authorized Official Last Name:
PRUITT
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
651-395-7585

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)





Copyright © 2007-2025 www.npivalidator.com