Healthcare Provider Details

I. General information

NPI: 1538321724
Provider Name (Legal Business Name): NIPOMO OPTOMETRY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2008
Last Update Date: 06/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 S FRONTAGE RD
NIPOMO CA
93444-8979
US

IV. Provider business mailing address

PO BOX 1423
NIPOMO CA
93444-1423
US

V. Phone/Fax

Practice location:
  • Phone: 805-929-1982
  • Fax:
Mailing address:
  • Phone: 805-929-1982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10723T
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierSD0107230
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name: DR. EILEEN OTTAVIANI
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 805-929-1982