Provider Demographics
NPI:1588070262
Name:CIRCLE CITY OPTOMETRY, INC
Entity type:Organization
Organization Name:CIRCLE CITY OPTOMETRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY / PRACT. ADMIN.
Authorized Official - Prefix:
Authorized Official - First Name:NANCI
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-735-1002
Mailing Address - Street 1:807 W GRAND BLVD
Mailing Address - Street 2:# A
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-3272
Mailing Address - Country:US
Mailing Address - Phone:951-735-1002
Mailing Address - Fax:951-735-9150
Practice Address - Street 1:807 W GRAND BLVD
Practice Address - Street 2:# A
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-3272
Practice Address - Country:US
Practice Address - Phone:951-735-1002
Practice Address - Fax:951-735-9150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5503TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA292905722Medicaid
SD0055030Medicare PIN