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General NPI Number Information
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NPI Number | 1326302316
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Entity Type | Organization
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Legal Business Name | DR. SKINNER OPTOMETRY P.C.
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Dates
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Enumeration Date | 06/25/2012
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Last Update Date | 06/25/2012
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Provider Practice Location Address
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Address Line | 8275 SIERRA AVE SUITE 103
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City | FONTANA
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State | CA
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Zip | 92335-3557
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Country | US
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Telephone | 909-822-1115
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Fax | 909-822-6346
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Provider Business Mailing Address
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Address Line | PO BOX 2200
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City | FONTANA
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State | CA
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Zip | 92334-2200
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Country | US
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Telephone | 909-822-1115
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Fax | 909-822-6346
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Authorized Official
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Title or Position | CEO
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Name | DR. MARK LOWREY SKINNER
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Credential | O.D.
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Telephone | 909-822-1115
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 9363T
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License Number State | CA
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