Healthcare Provider Details

I. General information

NPI: 1619973591
Provider Name (Legal Business Name): ALVARADO EYE ASSOCIATES MED CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7877 PARKWAY DR. SUITE# 100
LA MESA CA
91942-2000
US

IV. Provider business mailing address

75 ENTERPRISE STE 200
ALISO VIEJO CA
92656-2626
US

V. Phone/Fax

Practice location:
  • Phone: 619-460-3711
  • Fax: 619-460-2184
Mailing address:
  • Phone: 949-688-6205
  • Fax: 619-460-2184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. GLEN COOK
Title or Position: OWNER
Credential: MD
Phone: 619-460-3711