Provider Demographics
NPI:1306035118
Name:ADVANCED EYECARE PROFESSIONAL OPTOMETRIC GROUP
Entity type:Organization
Organization Name:ADVANCED EYECARE PROFESSIONAL OPTOMETRIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:V
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:818-240-0890
Mailing Address - Street 1:330 N BRAND BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-2308
Mailing Address - Country:US
Mailing Address - Phone:818-240-0890
Mailing Address - Fax:808-246-2540
Practice Address - Street 1:330 N BRAND BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2308
Practice Address - Country:US
Practice Address - Phone:818-240-0890
Practice Address - Fax:808-246-2540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9869152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1306035118Medicaid
CADP2509Medicare PIN
CA1306035118Medicaid
CABF492AMedicare PIN
CABR184Medicare PIN