Healthcare Provider Details

I. General information

NPI: 1114249026
Provider Name (Legal Business Name): TREVOR K IRISH OD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2010
Last Update Date: 11/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

991 E MONTE VISTA AVE
TURLOCK CA
95382-0636
US

IV. Provider business mailing address

991 E MONTE VISTA AVE
TURLOCK CA
95382-0636
US

V. Phone/Fax

Practice location:
  • Phone: 209-634-8591
  • Fax: 209-634-8596
Mailing address:
  • Phone: 209-634-8591
  • Fax: 209-634-8596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13477T
License Number StateCA

VIII. Authorized Official

Name: DR. TREVOR K IRISH
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 209-634-8591