=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225245772
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CIVILEYES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119 C ST
-----------------------------------------------------
City | PETALUMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94952-3069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-766-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 119 C ST
-----------------------------------------------------
City | PETALUMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94952-3069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-766-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DAVID LEE EVANS
-----------------------------------------------------
Credential | ABOC
-----------------------------------------------------
Telephone | 707-766-7000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | D7168
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------