=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760532436
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICKEY IIDA O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2223 S MOONEY BLVD VISALIA MALL #820
-----------------------------------------------------
City | VISALIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93277-6243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-739-8550
-----------------------------------------------------
Fax | 559-739-8636
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4983 N BLACKSTONE AVE
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93726-0109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-229-7956
-----------------------------------------------------
Fax | 559-221-2096
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 6053T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------