Provider Demographics
NPI:1114041688
Name:MOUNTAIN VISTA OPTICAL
Entity Type:Organization
Organization Name:MOUNTAIN VISTA OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:THORMAHLEN
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICAN
Authorized Official - Phone:951-692-1323
Mailing Address - Street 1:POB 1341
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92373
Mailing Address - Country:US
Mailing Address - Phone:951-692-1323
Mailing Address - Fax:866-258-0370
Practice Address - Street 1:10 E STATE ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4754
Practice Address - Country:US
Practice Address - Phone:951-692-1323
Practice Address - Fax:866-258-0370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD6920332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier