Provider Demographics
NPI:1932220324
Name:K J KOPECKO O D CHRISTINE L MAYER O D OPTOMETRY CORP
Entity type:Organization
Organization Name:K J KOPECKO O D CHRISTINE L MAYER O D OPTOMETRY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:MAYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-447-1332
Mailing Address - Street 1:2581 NUT TREE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-6915
Mailing Address - Country:US
Mailing Address - Phone:707-447-1332
Mailing Address - Fax:
Practice Address - Street 1:2581 NUT TREE RD
Practice Address - Street 2:SUITE C
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-6915
Practice Address - Country:US
Practice Address - Phone:707-447-1332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7004152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0022001Medicaid
5417820001Medicare NSC
CAGR0022001Medicaid