Healthcare Provider Details

I. General information

NPI: 1548202864
Provider Name (Legal Business Name): ANTELOPE VALLEY OPTOMETRIC CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 12/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 W AVENUE K SUITE A
LANCASTER CA
93534-6501
US

IV. Provider business mailing address

1745 W AVENUE K SUITE A
LANCASTER CA
93534-6501
US

V. Phone/Fax

Practice location:
  • Phone: 661-942-8437
  • Fax: 661-940-1959
Mailing address:
  • Phone: 661-942-8437
  • Fax: 661-940-1959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberCOR 486
License Number StateCA

VIII. Authorized Official

Name: DR. JERRY L MARTIN
Title or Position: CEO
Credential: O.D.
Phone: 661-942-8437