=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316680200
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFIC EYE INSTITUTE A MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2022
-----------------------------------------------------
Last Update Date | 04/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16177 KAMANA RD
-----------------------------------------------------
City | APPLE VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92307-1377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-345-8979
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 N 13TH AVE
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91786-4904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-277-2420
-----------------------------------------------------
Fax | 909-206-1097
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RICHMOND ROESKE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 909-277-2420
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------