Provider Demographics
NPI:1154537066
Name:SAN DIEGO OPTICAL
Entity type:Organization
Organization Name:SAN DIEGO OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARTER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-454-0033
Mailing Address - Street 1:7701 FAY AVE
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-4310
Mailing Address - Country:US
Mailing Address - Phone:858-454-0033
Mailing Address - Fax:
Practice Address - Street 1:7701 FAY AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-4310
Practice Address - Country:US
Practice Address - Phone:858-454-0033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD621156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty