Healthcare Provider Details

I. General information

NPI: 1356763759
Provider Name (Legal Business Name): ELITE EYECARE MEDICAL GROUP A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2014
Last Update Date: 10/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 VIBORG RD #240
SOLVANG CA
93463
US

IV. Provider business mailing address

910 E STOWELL RD
SANTA MARIA CA
93454-7001
US

V. Phone/Fax

Practice location:
  • Phone: 805-688-0707
  • Fax: 805-693-9839
Mailing address:
  • Phone: 805-925-2637
  • Fax: 805-347-0033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG71086
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT5812TPG
License Number StateCA

VIII. Authorized Official

Name: DR. KENNETH R KENDALL
Title or Position: CEO
Credential: OD
Phone: 805-925-2637