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General NPI Number Information
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NPI Number | 1891901294
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Entity Type | Organization
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Legal Business Name | WOODCREST VISION CENTER- OPTOMETRY
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Dates
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Enumeration Date | 05/15/2007
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Last Update Date | 06/30/2008
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Provider Practice Location Address
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Address Line | 17675 VAN BUREN BLVD SUITE C
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City | RIVERSIDE
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State | CA
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Zip | 92504
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Country | US
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Telephone | 951-780-0270
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Fax | 951-780-4807
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Provider Business Mailing Address
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Address Line | 17675 VAN BUREN BLVD SUITE C
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City | RIVERSIDE
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State | CA
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Zip | 92504
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Country | US
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Telephone | 951-780-0270
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Fax | 951-780-4807
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Authorized Official
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Title or Position | OWNER OPTOMETRIST
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Name | PETER SHAW MC MINN
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Credential | O.D.
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Telephone | 951-780-0270
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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 | OPT 6553T
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License Number State | CA
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