Healthcare Provider Details

I. General information

NPI: 1902893357
Provider Name (Legal Business Name): JOHN ARCHIBALD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 09/27/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3953 W STETSON AVE
HEMET CA
92545-9687
US

IV. Provider business mailing address

2390 E FLORIDA AVE SUITE 207
HEMET CA
92544-4707
US

V. Phone/Fax

Practice location:
  • Phone: 951-652-4343
  • Fax: 469-914-9372
Mailing address:
  • Phone: 951-652-6100
  • Fax: 951-658-7548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1177
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: