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General NPI Number Information
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NPI Number | 1972636397
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Entity Type | Organization
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Legal Business Name | HERITAGE EYE ASSOCIATES
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Dates
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Enumeration Date | 03/14/2007
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Last Update Date | 11/19/2024
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Provider Practice Location Address
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Address Line | 5762 E ACORN CT
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City | STOCKTON
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State | CA
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Zip | 95212-2622
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Country | US
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Telephone | 209-465-2581
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Fax |
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Provider Business Mailing Address
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Address Line | 445 W POPLAR ST
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City | STOCKTON
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State | CA
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Zip | 95203-2426
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Country | US
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Telephone | 209-465-5933
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Fax | 209-465-2568
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KENNETH V MISELIS
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Credential | M.D.
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Telephone | 209-465-5562
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | G502810
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License Number State | CA
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