Provider Demographics
NPI:1306059647
Name:GREGORY J FISCHER KELLEY OPTICIANS
Entity type:Organization
Organization Name:GREGORY J FISCHER KELLEY OPTICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:FISCHER
Authorized Official - Suffix:
Authorized Official - Credentials:DISPENSING OPTICIAN
Authorized Official - Phone:916-483-9293
Mailing Address - Street 1:4128 EL CAMINO AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821
Mailing Address - Country:US
Mailing Address - Phone:916-483-9293
Mailing Address - Fax:916-973-0407
Practice Address - Street 1:4128 EL CAMINO AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821
Practice Address - Country:US
Practice Address - Phone:916-483-9293
Practice Address - Fax:916-973-0407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD6619332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1265880001Medicare NSC
CA1265880001Medicare ID - Type Unspecified