1700050986 NPI number — RL EVANS, MA CARTER PROFESSIONAL CORPORATION

Table of content: (NPI 1700050986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700050986 NPI number — RL EVANS, MA CARTER PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RL EVANS, MA CARTER PROFESSIONAL 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:
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:
1700050986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 S MAGNOLIA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL CAJON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92020-6011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-444-3012
Provider Business Mailing Address Fax Number:
619-444-0232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 S MAGNOLIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CAJON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92020-6011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-444-9012
Provider Business Practice Location Address Fax Number:
619-444-0232
Provider Enumeration Date:
04/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CARTER
Authorized Official First Name:
MARILYN
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
OWNER / OPTOMETRIST
Authorized Official Telephone Number:
619-444-9012

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4790T , 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: OP4790 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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