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General NPI Number Information
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NPI Number | 1104395722
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Entity Type | Organization
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Legal Business Name | ADVANCED OPTOMETRIC SERVICES INC
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Dates
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Enumeration Date | 11/14/2018
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Last Update Date | 05/06/2019
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Provider Practice Location Address
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Address Line | 1208 FLOYD AVE BLDG C
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City | MODESTO
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State | CA
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Zip | 95350-2470
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Country | US
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Telephone | 209-521-7771
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Fax |
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Provider Business Mailing Address
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Address Line | 5942 ARENA WAY
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City | LIVINGSTON
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State | CA
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Zip | 95334-9314
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Country | US
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Telephone | 209-628-0110
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. BRANDIE J MEDINA
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Credential | OD
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Telephone | 209-628-0110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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