Provider Demographics
NPI:1902945751
Name:SIX RIVERS OPTICAL, INC.
Entity type:Organization
Organization Name:SIX RIVERS OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DODD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:707-445-2079
Mailing Address - Street 1:2039 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-3211
Mailing Address - Country:US
Mailing Address - Phone:707-445-2079
Mailing Address - Fax:707-445-2070
Practice Address - Street 1:2039 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3211
Practice Address - Country:US
Practice Address - Phone:707-445-2079
Practice Address - Fax:707-445-2070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2714156FX1800X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Not Answered332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADX002714FMedicaid
CA1448OtherMEDICAL EYE SERVICES
CA0378670001Medicare ID - Type Unspecified