Provider Demographics
NPI:1215174867
Name:ELISABETH S SWAN OPTOMETRY INC
Entity type:Organization
Organization Name:ELISABETH S SWAN OPTOMETRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELISABETH
Authorized Official - Middle Name:SARAH
Authorized Official - Last Name:SWAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:916-966-6080
Mailing Address - Street 1:4335 HAZEL AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-6669
Mailing Address - Country:US
Mailing Address - Phone:916-966-6080
Mailing Address - Fax:916-966-6919
Practice Address - Street 1:4335 HAZEL AVE
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-6669
Practice Address - Country:US
Practice Address - Phone:916-966-6080
Practice Address - Fax:916-966-6919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-18
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA9676T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADN431AOtherMEDI-CAL
CADN431AOtherMEDI-CAL
CAU41053Medicare UPIN