Healthcare Provider Details

I. General information

NPI: 1164641577
Provider Name (Legal Business Name): GUMM'S OPTICAL SHOPPE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 MAIN ST SUITE C
RED BLUFF CA
96080-2735
US

IV. Provider business mailing address

910 MAIN ST SUITE C
RED BLUFF CA
96080-2735
US

V. Phone/Fax

Practice location:
  • Phone: 530-527-2510
  • Fax: 530-529-1150
Mailing address:
  • Phone: 530-527-2510
  • Fax: 530-529-1150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberD 1940
License Number StateCA

VIII. Authorized Official

Name: JOHN GUMM
Title or Position: REGISTERED DISPENSING OPTICIAN
Credential:
Phone: 530-527-2510