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General NPI Number Information
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NPI Number | 1881832962
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Entity Type | Organization
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Legal Business Name | SHEA OPTOMETRIC CORPORATION
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Dates
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Enumeration Date | 01/28/2009
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Last Update Date | 03/03/2009
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Provider Practice Location Address
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Address Line | 2200 HARBOR BLVD STE D-130
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City | COSTA MESA
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State | CA
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Zip | 92627-2501
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Country | US
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Telephone | 949-642-7882
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Fax | 949-642-7792
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Provider Business Mailing Address
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Address Line | 2200 HARBOR BLVD STE D-130
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City | COSTA MESA
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State | CA
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Zip | 92627-2501
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Country | US
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Telephone | 949-642-7882
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Fax | 949-642-7792
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JACK C. SHEA
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Credential | O.D.
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Telephone | 949-642-7882
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number | 11538TPL
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 11538TPL
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License Number State | CA
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