1871746982 NPI number — MIKA E FU O D INC A CALIFORNIA PROFESSIONAL OPTOMETRIC CORPORATIO

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 1871746982 NPI number — MIKA E FU O D INC A CALIFORNIA PROFESSIONAL OPTOMETRIC CORPORATIO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIKA E FU O D INC A CALIFORNIA PROFESSIONAL OPTOMETRIC CORPORATIO
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:
GRAND VISION OPTOMETRY
Provider Other Organization Name Type Code:
3
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:
1871746982
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
151 S LAS POSAS RD
Provider Second Line Business Mailing Address:
STE 171
Provider Business Mailing Address City Name:
SAN MARCOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92078-2471
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-510-3130
Provider Business Mailing Address Fax Number:
760-510-3131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
151 S LAS POSAS RD
Provider Second Line Business Practice Location Address:
STE 171
Provider Business Practice Location Address City Name:
SAN MARCOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92078-2471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-510-3130
Provider Business Practice Location Address Fax Number:
760-510-3131
Provider Enumeration Date:
11/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FU
Authorized Official First Name:
MIKA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
760-510-3130

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT13304T , 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)





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