Healthcare Provider Details

I. General information

NPI: 1225245772
Provider Name (Legal Business Name): CIVILEYES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 C ST
PETALUMA CA
94952-3069
US

IV. Provider business mailing address

119 C ST
PETALUMA CA
94952-3069
US

V. Phone/Fax

Practice location:
  • Phone: 707-766-7000
  • Fax:
Mailing address:
  • Phone: 707-766-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberD7168
License Number StateCA

VIII. Authorized Official

Name: MR. DAVID LEE EVANS
Title or Position: OWNER
Credential: ABOC
Phone: 707-766-7000