Healthcare Provider Details

I. General information

NPI: 1821474537
Provider Name (Legal Business Name): EYENEZ INTEGRATED MANAGED EYE CARE NETWORK, A MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S GRAND AVE STE 106
GLENDORA CA
91741-4276
US

IV. Provider business mailing address

210 S GRAND AVE STE 106
GLENDORA CA
91741-4276
US

V. Phone/Fax

Practice location:
  • Phone: 626-335-0535
  • Fax: 626-963-0163
Mailing address:
  • Phone: 626-335-0535
  • Fax: 626-963-0163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MARK B KISLINGER
Title or Position: CEO
Credential: M.D.
Phone: 626-335-0535