1972688513 NPI number — FONTANA OPTOMETRIC GROUP, INC.

Table of content: (NPI 1972688513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972688513 NPI number — FONTANA OPTOMETRIC GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FONTANA OPTOMETRIC 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:
WILLIAM WONG AND DOUGLAS LEO, O.D.
Provider Other Organization Name Type Code:
4
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:
1972688513
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8381 JUNIPER AVE STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FONTANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92335-3431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-428-2020
Provider Business Mailing Address Fax Number:
844-274-0986

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16866 SEVILLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FONTANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92335-3561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-350-1524
Provider Business Practice Location Address Fax Number:
909-350-8546
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEO
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
909-428-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  06988 , 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: YYY48781Y , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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