Healthcare Provider Details

I. General information

NPI: 1346235603
Provider Name (Legal Business Name): SHASTA EYE MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3190 CHURN CREEK RD
REDDING CA
96002-2122
US

IV. Provider business mailing address

PO BOX 398986
SAN FRANCISCO CA
94139-5898
US

V. Phone/Fax

Practice location:
  • Phone: 530-223-2500
  • Fax: 530-226-1375
Mailing address:
  • Phone: 530-223-2500
  • Fax: 530-226-1375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GEORGE NEAL
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 844-377-6468