Provider Demographics
NPI:1346399433
Name:PACIFIC VISION MEDICAL CENTER
Entity type:Organization
Organization Name:PACIFIC VISION MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ENINGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-465-2020
Mailing Address - Street 1:515 E WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-8342
Mailing Address - Country:US
Mailing Address - Phone:707-465-2020
Mailing Address - Fax:707-465-6252
Practice Address - Street 1:515 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-8342
Practice Address - Country:US
Practice Address - Phone:707-465-2020
Practice Address - Fax:707-465-6252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAZZZ28910Z152W00000X, 207W00000X
CA0534820001332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0052190Medicaid
CAZZZ28910ZMedicare ID - Type UnspecifiedGROUP NUMBER
CACJ9992Medicare ID - Type UnspecifiedRR GROUP NUMBER
CA0538420001Medicare NSC