Provider Demographics
NPI:1972901684
Name:OPTOMETRIC CENTER AND EYEWEAR GALLERIA
Entity type:Organization
Organization Name:OPTOMETRIC CENTER AND EYEWEAR GALLERIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNDSY
Authorized Official - Middle Name:
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:CPOC
Authorized Official - Phone:925-743-1222
Mailing Address - Street 1:2551 SAN RAMON VALLEY BLVD.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1661
Mailing Address - Country:US
Mailing Address - Phone:925-743-1222
Mailing Address - Fax:925-743-1221
Practice Address - Street 1:2551 SAN RAMON VALLEY BLVD.
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1661
Practice Address - Country:US
Practice Address - Phone:925-743-1222
Practice Address - Fax:925-743-1221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-11
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5287T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0859240001Medicare NSC
CASD0052870Medicare PIN