Healthcare Provider Details

I. General information

NPI: 1770774457
Provider Name (Legal Business Name): BIRD ROCK OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

865 3RD AVE STE 121
CHULA VISTA CA
91911-1300
US

IV. Provider business mailing address

865 3RD AVE STE 121
CHULA VISTA CA
91911-1300
US

V. Phone/Fax

Practice location:
  • Phone: 619-427-2289
  • Fax: 619-426-3427
Mailing address:
  • Phone: 619-427-2289
  • Fax: 619-426-3427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number021264-06
License Number StateCA

VIII. Authorized Official

Name: MS. ELENA KRON
Title or Position: OWNER
Credential:
Phone: 619-427-2289