Healthcare Provider Details

I. General information

NPI: 1548465222
Provider Name (Legal Business Name): VISION CARE CENTER OF SOUTHEASTERN CA AN OPTOMETRIC CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 MAIN ST
BRAWLEY CA
92227-2351
US

IV. Provider business mailing address

PO BOX 1071
BRAWLEY CA
92227-1071
US

V. Phone/Fax

Practice location:
  • Phone: 760-351-2020
  • Fax: 760-344-4552
Mailing address:
  • Phone: 760-351-2020
  • Fax: 760-344-4552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number005636
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number005636
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number005636
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number005636
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number005636
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number005636
License Number StateCA

VIII. Authorized Official

Name: DR. DONALD LEE BARNISKE
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 760-351-2020