Healthcare Provider Details

I. General information

NPI: 1750909065
Provider Name (Legal Business Name): EYECARE SPECIALISTS MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2020
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81893 DR CARREON BLVD STE 101
INDIO CA
92201-0604
US

IV. Provider business mailing address

1595 E 17TH ST
SANTA ANA CA
92705-8506
US

V. Phone/Fax

Practice location:
  • Phone: 760-396-3600
  • Fax: 760-396-5379
Mailing address:
  • Phone: 714-399-0678
  • Fax: 714-276-6489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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