=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275619116
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOCUS VISION CLINIC OPTOMETRY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2006
-----------------------------------------------------
Last Update Date | 04/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1668 E 2ND ST STE B
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92223-3168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-845-4749
-----------------------------------------------------
Fax | 951-845-8625
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1668 E 2ND ST STE B
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92223-3168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-845-4749
-----------------------------------------------------
Fax | 951-845-8625
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TANYA L VANGUILDER
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 951-845-4749
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 12335T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------