Provider Demographics
NPI:1588273833
Name:FARTASH OD INC
Entity type:Organization
Organization Name:FARTASH OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-636-9920
Mailing Address - Street 1:734 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92880-1439
Mailing Address - Country:US
Mailing Address - Phone:951-737-2020
Mailing Address - Fax:735-737-2072
Practice Address - Street 1:734 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92880-1439
Practice Address - Country:US
Practice Address - Phone:951-737-2020
Practice Address - Fax:735-737-2072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1417263500Medicaid