Healthcare Provider Details

I. General information

NPI: 1982211793
Provider Name (Legal Business Name): I TO I LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 OAKDALE RD STE 525
MODESTO CA
95355
US

IV. Provider business mailing address

3401 OAKDALE RD STE 525
MODESTO CA
95355
US

V. Phone/Fax

Practice location:
  • Phone: 209-662-0282
  • Fax: 561-828-8367
Mailing address:
  • Phone: 209-662-0282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: JACKIE BENNETT
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 619-357-6146