Provider Demographics
NPI:1811654213
Name:EYES OF CONCORD
Entity type:Organization
Organization Name:EYES OF CONCORD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHASHATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-414-3513
Mailing Address - Street 1:901 SUNVALLEY BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-5816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 SUNVALLEY BLVD STE 110
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5816
Practice Address - Country:US
Practice Address - Phone:925-676-5638
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYES OF CONCORD INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000OtherOPTICAL