Healthcare Provider Details

I. General information

NPI: 1346399433
Provider Name (Legal Business Name): PACIFIC VISION MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 E WASHINGTON BLVD
CRESCENT CITY CA
95531-8342
US

IV. Provider business mailing address

515 E WASHINGTON BLVD
CRESCENT CITY CA
95531-8342
US

V. Phone/Fax

Practice location:
  • Phone: 707-465-2020
  • Fax: 707-465-6252
Mailing address:
  • Phone: 707-465-2020
  • Fax: 707-465-6252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberZZZ28910Z
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberZZZ28910Z
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number0534820001
License Number StateCA

VIII. Authorized Official

Name: LARRY A ENINGER
Title or Position: PARTNER
Credential: M.D.
Phone: 707-465-2020