Provider Demographics
NPI:1316270721
Name:BURBANK OPTOMETRIC CENTER, INC
Entity type:Organization
Organization Name:BURBANK OPTOMETRIC CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:SACHIKO
Authorized Official - Last Name:NISHIDA-EUGENIO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:818-845-3549
Mailing Address - Street 1:1032 N HOLLYWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-2525
Mailing Address - Country:US
Mailing Address - Phone:818-845-3549
Mailing Address - Fax:
Practice Address - Street 1:1032 N HOLLYWOOD WAY
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-2525
Practice Address - Country:US
Practice Address - Phone:818-845-3549
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-16
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9994T152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACT321AMedicare PIN