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General NPI Number Information
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NPI Number | 1376627000
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Entity Type | Organization
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Legal Business Name | MARK A JURY, OD A OPTOMETRIC PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 10/25/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 23905 CLINTON KEITH RD STE #115
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City | WILDOMAR
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State | CA
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Zip | 92595-7897
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Country | US
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Telephone | 951-304-9733
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Fax | 866-741-5945
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Provider Business Mailing Address
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Address Line | 23905 CLINTON KEITH RD STE #115
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City | WILDOMAR
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State | CA
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Zip | 92595-7897
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Country | US
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Telephone | 951-304-9733
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Fax | 866-741-5945
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | MARK A JURY
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Credential | OD
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Telephone | 951-304-9733
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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 | OPT9583
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License Number State | CA
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