Healthcare Provider Details

I. General information

NPI: 1881945038
Provider Name (Legal Business Name): MENIFEE VALLEY OPTOMETRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2012
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27168 NEWPORT RD SUITE 4
MENIFEE CA
92584-7383
US

IV. Provider business mailing address

27168 NEWPORT RD. SUITE 4
MENIFEE CA
92584-6526
US

V. Phone/Fax

Practice location:
  • Phone: 951-679-0545
  • Fax: 951-679-6154
Mailing address:
  • Phone: 951-679-0545
  • Fax: 951-679-6154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT8225TLG
License Number StateCA

VIII. Authorized Official

Name: DR. ERIC M. FENNEMA
Title or Position: OWNER
Credential: O.D.
Phone: 951-679-0545