Provider Demographics
NPI:1083874648
Name:EYE CENTER OF NORTHERN CALIFORNIA
Entity Type:Organization
Organization Name:EYE CENTER OF NORTHERN CALIFORNIA
Other - Org Name:ELLIS EYE & LASER MEDICAL CNTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-525-2600
Mailing Address - Street 1:6500 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-3667
Mailing Address - Country:US
Mailing Address - Phone:510-525-2600
Mailing Address - Fax:510-524-1887
Practice Address - Street 1:6500 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-3667
Practice Address - Country:US
Practice Address - Phone:510-525-2600
Practice Address - Fax:510-524-1887
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYE CENTER OF NORTHERN CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA140000382261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG000197420Medicaid
CAZZZ38409ZOtherPTAN#
CAG000197420Medicaid