Healthcare Provider Details

I. General information

NPI: 1568657278
Provider Name (Legal Business Name): PROFESSIONAL EYECARE OPTOMETRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 COUNTRY CLUB DR STE A
MORAGA CA
94556-1950
US

IV. Provider business mailing address

1030 COUNTRY CLUB DR STE A
MORAGA CA
94556-1950
US

V. Phone/Fax

Practice location:
  • Phone: 925-376-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6110
License Number StateCA

VIII. Authorized Official

Name: MS. LOIS ZAVODA
Title or Position: OPTOMETRIC ASSISTANT
Credential:
Phone: 925-376-2020