Provider Demographics
NPI:1124156120
Name:TRI-COUNTY EYE INSTITUTE INC
Entity type:Organization
Organization Name:TRI-COUNTY EYE INSTITUTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING LEAD
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GONCIARCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-737-6363
Mailing Address - Street 1:1124 S MAIN ST
Mailing Address - Street 2:# 101
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-4449
Mailing Address - Country:US
Mailing Address - Phone:951-737-6363
Mailing Address - Fax:951-272-6723
Practice Address - Street 1:1124 S MAIN ST
Practice Address - Street 2:# 101
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-4449
Practice Address - Country:US
Practice Address - Phone:951-737-6363
Practice Address - Fax:951-272-6723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ29395ZMedicare PIN