Provider Demographics
NPI:1073563706
Name:ANTELOPE VALLEY FAMILY OPTOMETRY, INC
Entity Type:Organization
Organization Name:ANTELOPE VALLEY FAMILY OPTOMETRY, INC
Other - Org Name:ANTELOPE VALLEY FAMILY OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:661-267-0026
Mailing Address - Street 1:2720 E PALMDALE BLVD
Mailing Address - Street 2:SUITE 133
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-4930
Mailing Address - Country:US
Mailing Address - Phone:661-267-0026
Mailing Address - Fax:661-267-0892
Practice Address - Street 1:2720 E PALMDALE BLVD STE 133
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-4930
Practice Address - Country:US
Practice Address - Phone:661-267-0026
Practice Address - Fax:661-267-0892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11428T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6204141Medicaid