=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508140062
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISIONCARE OF CALIFORNIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2011
-----------------------------------------------------
Last Update Date | 10/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1095 ROSEVILLE SQ
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95678-2809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-782-9985
-----------------------------------------------------
Fax | 916-782-9987
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1095 ROSEVILLE SQ
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95678-2809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-782-9985
-----------------------------------------------------
Fax | 916-782-9987
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NICHOLAS SHASHATI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-454-4547
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------