=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912176454
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYEDESIGNS OPTOMETRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2008
-----------------------------------------------------
Last Update Date | 02/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1436 4TH ST
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94901-2812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-454-0354
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1436 4TH ST
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94901-2812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-454-0354
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PARTNER
-----------------------------------------------------
Name | RONALD SANTIAGO GARCIA
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 415-454-0354
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 9673T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------