Healthcare Provider Details

I. General information

NPI: 1801518790
Provider Name (Legal Business Name): FOURTH OPTOMETRIC CARE OF CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7379 INDIANA AVE
RIVERSIDE CA
92504-4547
US

IV. Provider business mailing address

3333 QUALITY DR
RANCHO CORDOVA CA
95670-7985
US

V. Phone/Fax

Practice location:
  • Phone: 951-684-7822
  • Fax:
Mailing address:
  • Phone: 704-712-0564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: BRITTANY HARRISON
Title or Position: DIRECTOR
Credential:
Phone: 512-316-4603