Healthcare Provider Details

I. General information

NPI: 1316680200
Provider Name (Legal Business Name): PACIFIC EYE INSTITUTE A MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16177 KAMANA RD
APPLE VALLEY CA
92307-1377
US

IV. Provider business mailing address

555 N 13TH AVE
UPLAND CA
91786-4904
US

V. Phone/Fax

Practice location:
  • Phone: 800-345-8979
  • Fax:
Mailing address:
  • Phone: 909-277-2420
  • Fax: 909-206-1097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHMOND ROESKE
Title or Position: OWNER
Credential: MD
Phone: 909-277-2420