Healthcare Provider Details

I. General information

NPI: 1548339112
Provider Name (Legal Business Name): MANTECA OPTOMETRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 N MAPLE AVE
MANTECA CA
95336-4503
US

IV. Provider business mailing address

1532 BENNINGTON CT
STOCKTON CA
95209-4556
US

V. Phone/Fax

Practice location:
  • Phone: 209-239-3504
  • Fax: 209-239-0741
Mailing address:
  • Phone: 209-477-3888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number12388T
License Number StateCA

VIII. Authorized Official

Name: LEANNE LEE
Title or Position: PARTNER
Credential: O.D.
Phone: 209-239-3504