Provider Demographics
NPI:1528144011
Name:MAISON OPTIQUE OPTOMETRIC CENTER
Entity type:Organization
Organization Name:MAISON OPTIQUE OPTOMETRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNERSHIP/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ENRIQUEZ
Authorized Official - Last Name:TAMAYO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-325-7799
Mailing Address - Street 1:3525 PACIFIC COAST HWY
Mailing Address - Street 2:SUITE E
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-6655
Mailing Address - Country:US
Mailing Address - Phone:310-325-7799
Mailing Address - Fax:310-325-7790
Practice Address - Street 1:3525 PACIFIC COAST HWY
Practice Address - Street 2:SUITE E
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6655
Practice Address - Country:US
Practice Address - Phone:310-325-7799
Practice Address - Fax:310-325-7790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10737TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5436550001OtherMEDICARE DME-MAC
CASDO107370Medicaid
CASDO119690Medicaid
CAGSD005160Medicaid
CAU92012Medicare UPIN
CA5436550001Medicare NSC
CA5436550001OtherMEDICARE DME-MAC
CAWOP11969CMedicare ID - Type Unspecified
CASDO107370Medicaid
CAW18580Medicare ID - Type Unspecified