=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295141562
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EL DORADO HILLS VISION CENTER OPTOMETRY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2014
-----------------------------------------------------
Last Update Date | 07/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3955 PARK DR SUITE 1
-----------------------------------------------------
City | EL DORADO HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95762-4569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-292-5666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3955 PARK DR SUITE 1
-----------------------------------------------------
City | EL DORADO HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95762-4569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | KAMBIZ KHORRAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-292-5666
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------