Healthcare Provider Details

I. General information

NPI: 1023586955
Provider Name (Legal Business Name): KEVIN CAMBRA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1839 W 11TH ST
TRACY CA
95376-3727
US

IV. Provider business mailing address

1839 W 11TH ST
TRACY CA
95376-3727
US

V. Phone/Fax

Practice location:
  • Phone: 510-301-8317
  • 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: KEVIN CAMBRA
Title or Position: OWNER
Credential:
Phone: 510-301-8317