Healthcare Provider Details

I. General information

NPI: 1215009618
Provider Name (Legal Business Name): EVANS OPTOMETRY CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71956 MAGNESIA FALLS DR
RANCHO MIRAGE CA
92270-4901
US

IV. Provider business mailing address

71956 MAGNESIA FALLS DR
RANCHO MIRAGE CA
92270-4901
US

V. Phone/Fax

Practice location:
  • Phone: 760-674-8806
  • Fax: 760-674-8826
Mailing address:
  • Phone: 760-674-8806
  • Fax: 760-674-8826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6648T
License Number StateCA

VIII. Authorized Official

Name: KAREN EVANS
Title or Position: ADMINISTRATOR
Credential:
Phone: 760-674-8806