Healthcare Provider Details

I. General information

NPI: 1164083663
Provider Name (Legal Business Name): RIVERSIDE OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 PARK MARINA DR
REDDING CA
96001-2822
US

IV. Provider business mailing address

2801 PARK MARINA DR
REDDING CA
96001-2822
US

V. Phone/Fax

Practice location:
  • Phone: 530-244-2273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. SCOTT SUMSION
Title or Position: ADMINISTRATOR
Credential:
Phone: 530-244-2273