Healthcare Provider Details

I. General information

NPI: 1164466488
Provider Name (Legal Business Name): KOLBERG OCULAR PRODUCTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9663 TIERRA GRANDE ST SUITE 201
SAN DIEGO CA
92126-4568
US

IV. Provider business mailing address

9663 TIERRA GRANDE ST SUITE 201
SAN DIEGO CA
92126-4568
US

V. Phone/Fax

Practice location:
  • Phone: 858-695-2021
  • Fax: 858-695-2712
Mailing address:
  • Phone: 858-695-2021
  • Fax: 858-695-2712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: GORDON I KOLBERG
Title or Position: PRESIDENT
Credential: B.C.O.
Phone: 858-695-2021