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General NPI Number Information
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NPI Number | 1528277175
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Entity Type | Organization
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Legal Business Name | OPTOMETRIC CENTERS
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 12968 FREDERICK ST STE A
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City | MORENO VALLEY
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State | CA
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Zip | 92553-5229
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Country | US
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Telephone | 951-924-1877
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Fax | 951-485-3580
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Provider Business Mailing Address
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Address Line | 12968 FREDERICK ST
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City | MORENO VALLEY
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State | CA
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Zip | 92553-5229
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Country | US
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Telephone | 951-924-1877
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Fax | 951-485-3580
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Authorized Official
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Title or Position | OPTOMOTRIST
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Name | MR. ETHAN M CLAYTON
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Credential | O.D.
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Telephone | 951-924-1877
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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 | 12701T
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License Number State | CA
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