Provider Demographics
NPI:1285771592
Name:VALLEJO OPTOMETRY GROUP
Entity type:Organization
Organization Name:VALLEJO OPTOMETRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BACH-KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:707-554-1773
Mailing Address - Street 1:2103 REDWOOD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-3608
Mailing Address - Country:US
Mailing Address - Phone:707-554-1773
Mailing Address - Fax:707-554-1782
Practice Address - Street 1:2103 REDWOOD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-3608
Practice Address - Country:US
Practice Address - Phone:707-554-1773
Practice Address - Fax:707-554-1782
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALNUT CREEK OPTOMETRY GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-30
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10544152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ00757ZOtherMEDICARE GROUP NUMBER
CAZZZ00757ZOtherMEDICARE GROUP NUMBER
CAZZZ00757ZOtherMEDICARE GROUP NUMBER
CA=========OtherEIN