Provider Demographics
NPI:1083743066
Name:EAST BAY VISION CENTER OPTOMETRY INC
Entity Type:Organization
Organization Name:EAST BAY VISION CENTER OPTOMETRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:LO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:510-796-9600
Mailing Address - Street 1:34420 FREMONT BLVD
Mailing Address - Street 2:STE E
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94555-3323
Mailing Address - Country:US
Mailing Address - Phone:510-796-9600
Mailing Address - Fax:510-796-9691
Practice Address - Street 1:34420 FREMONT BLVD
Practice Address - Street 2:STE E
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94555-3323
Practice Address - Country:US
Practice Address - Phone:510-796-9600
Practice Address - Fax:510-796-9691
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST BAY VISION CENTER OPTOMETRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-05
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8533T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0085332Medicaid
CAZZZ26998ZMedicare PIN