Provider Demographics
NPI:1972636397
Name:HERITAGE EYE ASSOCIATES
Entity type:Organization
Organization Name:HERITAGE EYE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:V
Authorized Official - Last Name:MISELIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-465-5562
Mailing Address - Street 1:445 W POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95203-2426
Mailing Address - Country:US
Mailing Address - Phone:209-465-5933
Mailing Address - Fax:209-465-2568
Practice Address - Street 1:5762 E ACORN CT
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95212-2622
Practice Address - Country:US
Practice Address - Phone:209-465-2581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG502810332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA076183001OtherMEDICARE DMERC