Healthcare Provider Details

I. General information

NPI: 1700041043
Provider Name (Legal Business Name): SANDRA DAVIDSON, O.D. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 CENTRAL AVE STE 101
RIVERSIDE CA
92506-2374
US

IV. Provider business mailing address

4515 CENTRAL AVE STE 101
RIVERSIDE CA
92506-2374
US

V. Phone/Fax

Practice location:
  • Phone: 951-784-2420
  • Fax: 951-784-4713
Mailing address:
  • Phone: 951-784-2420
  • Fax: 951-784-4713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. SANDRA DAVIDSON
Title or Position: OWNER
Credential: O.D
Phone: 951-784-2420