Healthcare Provider Details

I. General information

NPI: 1750488169
Provider Name (Legal Business Name): EYECARE SPECIALISTS MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7677 CENTER AVE SUITE 301
HUNTINGTON BEACH CA
92647-3074
US

IV. Provider business mailing address

7677 CENTER AVE. SUITE 301
HUNTINGTON BEACH CA
92647-3074
US

V. Phone/Fax

Practice location:
  • Phone: 714-901-2007
  • Fax: 714-901-2003
Mailing address:
  • Phone: 714-901-2004
  • Fax: 714-901-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberW14969F
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberW14969F
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: FELISA MARISOL GALINDO
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 626-305-9100