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General NPI Number Information
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NPI Number | 1306035118
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Entity Type | Organization
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Legal Business Name | ADVANCED EYECARE PROFESSIONAL OPTOMETRIC GROUP
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Dates
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Enumeration Date | 10/17/2007
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Last Update Date | 09/21/2009
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Provider Practice Location Address
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Address Line | 330 N BRAND BLVD SUITE 110
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City | GLENDALE
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State | CA
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Zip | 91203-2308
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Country | US
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Telephone | 818-240-0890
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Fax | 808-246-2540
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Provider Business Mailing Address
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Address Line | 330 N BRAND BLVD SUITE 110
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City | GLENDALE
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State | CA
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Zip | 91203-2308
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Country | US
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Telephone | 818-240-0890
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Fax | 808-246-2540
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Authorized Official
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Title or Position | OWNER
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Name | DR. RONALD V BLACK
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Credential | O.D.
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Telephone | 818-240-0890
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT9869
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License Number State | CA
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