Provider Demographics
NPI:1043588346
Name:IMPERIAL VALLEY OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:IMPERIAL VALLEY OPTOMETRIC CORPORATION
Other - Org Name:OPTOM EYES VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAY
Authorized Official - Middle Name:C
Authorized Official - Last Name:TAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-336-3003
Mailing Address - Street 1:3451 S DOGWOOD AVE
Mailing Address - Street 2:STE 1334
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243
Mailing Address - Country:US
Mailing Address - Phone:760-336-3003
Mailing Address - Fax:888-210-5799
Practice Address - Street 1:5638 MISSION CENTER RD
Practice Address - Street 2:STE 103
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4348
Practice Address - Country:US
Practice Address - Phone:619-295-2900
Practice Address - Fax:888-210-5799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD005600Medicaid