1588091367 NPI number — GAGNON VISION MEDICAL GROUP INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588091367 NPI number — GAGNON VISION MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GAGNON VISION MEDICAL GROUP 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:
1588091367
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5575 W LAS POSITAS BLVD
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
PLEASANTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94588-5801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-460-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28 FENTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIVERMORE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94550-4144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-449-4000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GAGNON
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
925-822-8776

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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