Provider Demographics
NPI:1063927903
Name:PENINSULA LASER EYE OPTICAL
Entity type:Organization
Organization Name:PENINSULA LASER EYE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BEERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-961-2585
Mailing Address - Street 1:1174 CASTRO ST STE 110
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-2572
Mailing Address - Country:US
Mailing Address - Phone:650-961-0672
Mailing Address - Fax:650-961-3637
Practice Address - Street 1:1174 CASTRO ST STE 110
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-2572
Practice Address - Country:US
Practice Address - Phone:650-961-0672
Practice Address - Fax:650-961-3637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier