Healthcare Provider Details

I. General information

NPI: 1750617940
Provider Name (Legal Business Name): WAYNE A. NISHIO, O.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2009
Last Update Date: 10/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 N CLOVIS AVE SUITE 101
CLOVIS CA
93612-0361
US

IV. Provider business mailing address

145 N CLOVIS AVE SUITE 101
CLOVIS CA
93612-0361
US

V. Phone/Fax

Practice location:
  • Phone: 559-299-3179
  • Fax:
Mailing address:
  • Phone: 559-299-3179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number7298T
License Number StateCA

VIII. Authorized Official

Name: WAYNE NISHIO
Title or Position: OWNER
Credential:
Phone: 559-299-3179