=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295729382
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE ASSOCIATES OF SEBASTOPOL MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2005
-----------------------------------------------------
Last Update Date | 09/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6880 PALM AVE
-----------------------------------------------------
City | SEBASTOPOL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95472-4270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-823-7628
-----------------------------------------------------
Fax | 707-823-1521
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6880 PALM AVE
-----------------------------------------------------
City | SEBASTOPOL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95472-4270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-823-7628
-----------------------------------------------------
Fax | 707-823-1521
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MS. KIM KHAMTHEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 707-823-0229
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------