Healthcare Provider Details

I. General information

NPI: 1669246104
Provider Name (Legal Business Name): EYECARE SPECIALISTS MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2023
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7677 CENTER AVE STE 102
HUNTINGTON BEACH CA
92647-3030
US

IV. Provider business mailing address

14726 RAMONA AVE STE 203
CHINO CA
91710-5730
US

V. Phone/Fax

Practice location:
  • Phone: 714-316-0802
  • Fax: 714-316-0804
Mailing address:
  • Phone: 626-305-9100
  • Fax: 626-305-0152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DWAYNE K LOGAN
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 562-938-9945