=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295860187
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR HARVEY LEDESMA OPTOMETRY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 05/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 490 ALABAMA ST SUITE 107
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92373-8089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-793-5565
-----------------------------------------------------
Fax | 909-793-5575
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 490 ALABAMA ST SUITE 107
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92373-8089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-793-5565
-----------------------------------------------------
Fax | 909-793-5575
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. HARVEY DENNIS LEDESMA
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 909-793-5565
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | CAOPT12094TPL
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------