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General NPI Number Information
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NPI Number | 1417646597
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Entity Type | Organization
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Legal Business Name | EYES ON EASTLAKE OPTOMETRY INC
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Dates
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Enumeration Date | 05/03/2023
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Last Update Date | 05/04/2023
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Provider Practice Location Address
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Address Line | 1360 EASTLAKE PKWY
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City | CHULA VISTA
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State | CA
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Zip | 91915-4116
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Country | US
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Telephone | 619-482-1603
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Fax |
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Provider Business Mailing Address
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Address Line | 1360 EASTLAKE PKWY
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City | CHULA VISTA
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State | CA
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Zip | 91915-4116
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | AILLEEN DEOCADIZ JACOB
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Credential | OD
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Telephone | 954-854-5778
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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 |
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License Number State |
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