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General NPI Number Information
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NPI Number | 1851522411
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Entity Type | Organization
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Legal Business Name | PETALUMA EYE CARE OPTOMETRIC ASSOCIATES, INC. A PROFESSIONAL CORP.
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Dates
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Enumeration Date | 07/30/2009
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Last Update Date | 02/14/2014
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Provider Practice Location Address
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Address Line | 129 KELLER ST
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City | PETALUMA
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State | CA
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Zip | 94952-2934
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Country | US
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Telephone | 707-763-2020
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Fax | 707-763-4735
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Provider Business Mailing Address
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Address Line | 129 KELLER ST
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City | PETALUMA
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State | CA
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Zip | 94952-2934
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Country | US
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Telephone | 707-763-2020
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Fax | 707-763-4735
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Authorized Official
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Title or Position | OWNER
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Name | RONALD LEE HARRIS
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Credential | O.D.
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Telephone | 707-763-2020
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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 | 04916T
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License Number State | CA
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