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General NPI Number Information
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NPI Number | 1629152814
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Entity Type | Organization
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Legal Business Name | EASTLAKE LASER EYE ASSOCIATES
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Dates
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Enumeration Date | 10/24/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 890 EASTLAKE PARKWAY SUITE 205
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City | CHULA VISTA
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State | CA
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Zip | 91914
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Country | US
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Telephone | 619-216-0400
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Fax | 619-216-0440
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Provider Business Mailing Address
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Address Line | 890 EASTLAKE PARKWAY SUITE 205
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City | CHULA VISTA
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State | CA
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Zip | 91914
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Country | US
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Telephone | 619-216-0400
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Fax | 619-216-0440
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Authorized Official
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Title or Position | MEMBER
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Name | RICHARD STEVEN SABLE
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Credential | MD
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Telephone | 619-216-0400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1700X
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Taxonomy Name | Ocularist
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License Number | G56599
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License Number State | CA
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