Provider Demographics
NPI:1124222997
Name:20 -20 VISION ASSOCIATES OPTOMETRY
Entity Type:Organization
Organization Name:20 -20 VISION ASSOCIATES OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER, PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:M
Authorized Official - Last Name:EVERITT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:951-684-7822
Mailing Address - Street 1:6377 RIVERSIDE AVE
Mailing Address - Street 2:SUITE 190
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3124
Mailing Address - Country:US
Mailing Address - Phone:951-684-7822
Mailing Address - Fax:951-684-0733
Practice Address - Street 1:6377 RIVERSIDE AVE
Practice Address - Street 2:SUITE 190
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3124
Practice Address - Country:US
Practice Address - Phone:951-684-7822
Practice Address - Fax:951-684-0733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10316T152W00000X
CA5187T152W00000X
CA13309T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0103160Medicaid
CASD0051870Medicaid
CADB2495OtherRR MEDICARE
CASD0103161Medicare PIN
CASD0051871Medicare PIN
CASD0103160Medicaid
CAP00094927Medicare PIN
CAZZZ20073ZMedicare ID - Type Unspecified
CASD0133090Medicare PIN
CADB2495OtherRR MEDICARE
CAU60200Medicare UPIN
CA4379800001Medicare NSC