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General NPI Number Information
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NPI Number | 1114041688
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Entity Type | Organization
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Legal Business Name | MOUNTAIN VISTA OPTICAL
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Dates
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Enumeration Date | 03/19/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 10 E STATE ST
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City | REDLANDS
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State | CA
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Zip | 92373-4754
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Country | US
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Telephone | 951-692-1323
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Fax | 866-258-0370
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Provider Business Mailing Address
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Address Line | POB 1341
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City | SAN JACINTO
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State | CA
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Zip | 92373
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Country | US
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Telephone | 951-692-1323
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Fax | 866-258-0370
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Authorized Official
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Title or Position | PRESIDENT
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Name | PATRICIA A THORMAHLEN
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Credential | OPTICAN
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Telephone | 951-692-1323
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | D6920
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License Number State | CA
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