Healthcare Provider Details

I. General information

NPI: 1407932619
Provider Name (Legal Business Name): PACIFIC EYE INSTITUTE A MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N 13TH AVE
UPLAND CA
91786-4904
US

IV. Provider business mailing address

555 N 13TH AVE
UPLAND CA
91786-4904
US

V. Phone/Fax

Practice location:
  • Phone: 909-982-8846
  • Fax: 909-931-0791
Mailing address:
  • Phone: 909-982-8846
  • Fax: 909-931-0791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number240000525
License Number StateCA

VIII. Authorized Official

Name: RICHMOND ROESKE
Title or Position: PHYSICIAN/OWNER
Credential:
Phone: 800-345-8979