Provider Demographics
NPI:1154420602
Name:GRIFFIN OPTOMETRIC TALEGA INC
Entity type:Organization
Organization Name:GRIFFIN OPTOMETRIC TALEGA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:AUBURN
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:949-940-0200
Mailing Address - Street 1:1001 AVE PICO
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6956
Mailing Address - Country:US
Mailing Address - Phone:949-940-0200
Mailing Address - Fax:949-940-0201
Practice Address - Street 1:1001 AVE PICO
Practice Address - Street 2:SUITE A
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6956
Practice Address - Country:US
Practice Address - Phone:949-940-0200
Practice Address - Fax:949-940-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1154420602152W00000X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5831860001Medicare NSC
CAWY3202Medicare UPIN