Provider Demographics
NPI:1063459725
Name:SOUTH COAST EYE CARE CENTERS A COMP OPHTHALMOLOGY MEDICAL GRP INC.
Entity Type:Organization
Organization Name:SOUTH COAST EYE CARE CENTERS A COMP OPHTHALMOLOGY MEDICAL GRP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-588-2020
Mailing Address - Street 1:23961 CALLE DE LA MAGDALENA
Mailing Address - Street 2:STE. 302
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3616
Mailing Address - Country:US
Mailing Address - Phone:949-588-2020
Mailing Address - Fax:949-588-0336
Practice Address - Street 1:23961 CALLE DE LA MAGDALENA
Practice Address - Street 2:STE. 302
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3616
Practice Address - Country:US
Practice Address - Phone:949-588-2020
Practice Address - Fax:949-588-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36573207W00000X
CAG73434207W00000X
CAA77935207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102520Medicaid
CAG18838Medicare UPIN
CAA46731Medicare UPIN
CAW12044Medicare PIN
CAH37968Medicare UPIN
CAGR0102520Medicaid
CAW12044BMedicare PIN
CACK3068Medicare PIN