Healthcare Provider Details

I. General information

NPI: 1457756363
Provider Name (Legal Business Name): EYEXAM OF CA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 GLENDALE GALLERIA
GLENDALE CA
91210-1301
US

IV. Provider business mailing address

11751 RANCHITO ST
EL MONTE CA
91732-1317
US

V. Phone/Fax

Practice location:
  • Phone: 818-552-4440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number15134
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number15134
License Number StateCA

VIII. Authorized Official

Name: TAYLOR TEDDER
Title or Position: REGIONAL DIRECTOR OF EYEXAM OF CA
Credential:
Phone: 805-217-2974