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General NPI Number Information
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NPI Number | 1669697348
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Entity Type | Organization
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Legal Business Name | SHASTA VISION GROUP AN OPTOMETRIC CORPORATION
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Dates
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Enumeration Date | 04/16/2007
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Last Update Date | 06/12/2018
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Provider Practice Location Address
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Address Line | 110 CHESTNUT ST
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City | MOUNT SHASTA
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State | CA
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Zip | 96067
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Country | US
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Telephone | 530-926-2033
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Fax | 530-926-3722
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Provider Business Mailing Address
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Address Line | 110 CHESTNUT ST
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City | MOUNT SHASTA
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State | CA
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Zip | 96067-2209
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Country | US
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Telephone | 530-926-2033
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Fax | 530-926-3722
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Authorized Official
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Title or Position | OWNER
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Name | DR. ANNELLE G MAYGREN
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Credential | OD
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Telephone | 530-926-2033
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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 | 152W00000X
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License Number State | CA
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