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General NPI Number Information
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NPI Number | 1679989594
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Entity Type | Organization
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Legal Business Name | S. MACK BROWN OD OPTOMETRIC CORPORATION
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Dates
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Enumeration Date | 07/11/2014
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Last Update Date | 07/11/2014
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Provider Practice Location Address
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Address Line | 716 S DORA ST
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City | UKIAH
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State | CA
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Zip | 95482-5336
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Country | US
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Telephone | 707-462-5361
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Fax | 707-462-2457
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Provider Business Mailing Address
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Address Line | 716 S DORA ST
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City | UKIAH
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State | CA
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Zip | 95482-5336
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Country | US
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Telephone | 707-462-5361
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Fax | 707-462-2457
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. S. MACK BROWN
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Credential | OD
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Telephone | 707-462-5361
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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 | 4748T
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License Number State | CA
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