Healthcare Provider Details

I. General information

NPI: 1780954818
Provider Name (Legal Business Name): SPEKTACLES OPTOMETRY AND EYEWEAR INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2027 SAN ELIJO AVE SUITE 2027
CARDIFF CA
92007-1726
US

IV. Provider business mailing address

2027 SAN ELIJO AVE SUITE 2027
CARDIFF CA
92007-1726
US

V. Phone/Fax

Practice location:
  • Phone: 760-452-2895
  • Fax: 760-452-2898
Mailing address:
  • Phone: 760-452-2895
  • Fax: 760-452-2898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1154T
License Number StateCA

VIII. Authorized Official

Name: DR. TANIA CORRY KACZANOWSKI
Title or Position: OPTOMETRIST/OWNER
Credential: O.D.
Phone: 760-452-2895