=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366452369
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARENA EYE CARE, INC., AN OPTOMETRIC CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2087 ARENA BLVD STE 120
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95834-2315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-419-8167
-----------------------------------------------------
Fax | 916-419-6398
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2087 ARENA BLVD STE 120
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95834-2315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-419-8167
-----------------------------------------------------
Fax | 916-419-6398
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KRISTER LARSON HOLMBERG
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 916-419-8167
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1170
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------