Provider Demographics
NPI:1063603710
Name:ACEVEDO, MANUEL (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:
Last Name:ACEVEDO
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:ILLUSION
Other - Middle Name:
Other - Last Name:OPTICAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:711 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:CA
Mailing Address - Zip Code:93657-4109
Mailing Address - Country:US
Mailing Address - Phone:559-875-4237
Mailing Address - Fax:559-876-2300
Practice Address - Street 1:632 O ST
Practice Address - Street 2:
Practice Address - City:SANGER
Practice Address - State:CA
Practice Address - Zip Code:93657-2417
Practice Address - Country:US
Practice Address - Phone:559-875-4237
Practice Address - Fax:559-876-2300
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD 7230156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician