Provider Demographics
NPI:1063649564
Name:DANIEL R. TAKETA
Entity Type:Organization
Organization Name:DANIEL R. TAKETA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TAKETA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:805-736-7010
Mailing Address - Street 1:611 E OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-6914
Mailing Address - Country:US
Mailing Address - Phone:805-736-7010
Mailing Address - Fax:805-736-7589
Practice Address - Street 1:611 E OCEAN AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6914
Practice Address - Country:US
Practice Address - Phone:805-736-7010
Practice Address - Fax:805-736-7589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7368TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0924930001Medicare NSC