Provider Demographics
NPI:1215062906
Name:GOLDEN TRIANGLE OPTOMETRICS
Entity type:Organization
Organization Name:GOLDEN TRIANGLE OPTOMETRICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-698-4575
Mailing Address - Street 1:25460 MEDICAL CENTER DR
Mailing Address - Street 2:STE. 103
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5985
Mailing Address - Country:US
Mailing Address - Phone:951-698-4575
Mailing Address - Fax:
Practice Address - Street 1:25460 MEDICAL CENTER DR
Practice Address - Street 2:STE. 103
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5985
Practice Address - Country:US
Practice Address - Phone:951-698-4575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7468T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0074680OtherPERSONAL ID NUMBER
CASD0074680OtherPERSONAL ID NUMBER