1932612702 NPI number — MICHELLE TIMENOVICH O.D., A PROFESSIONAL OPTOMETRY CORP.

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 1932612702 NPI number — MICHELLE TIMENOVICH O.D., A PROFESSIONAL OPTOMETRY CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHELLE TIMENOVICH O.D., A PROFESSIONAL OPTOMETRY CORP.
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:
1932612702
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9367 RIBERENA CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATASCADERO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93422-6252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 NIBLICK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASO ROBLES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93446-4842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-237-0275
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/14/2017

Additional Information

Authorized Official

Authorized Official Last Name:
TIMENOVICH
Authorized Official First Name:
MICHELINA
Authorized Official Middle Name:
LILLIAN
Authorized Official Title or Position:
OPTOMETRIST/SUBLEASE OWNER
Authorized Official Telephone Number:
818-430-3336

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  14961TLG , 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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