Provider Demographics
NPI:1134140346
Name:EYE SITE SACRAMENTO MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:EYE SITE SACRAMENTO MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:VAN DUYN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-452-8105
Mailing Address - Street 1:4925 J ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-3828
Mailing Address - Country:US
Mailing Address - Phone:916-452-8105
Mailing Address - Fax:916-452-4659
Practice Address - Street 1:4925 J ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3828
Practice Address - Country:US
Practice Address - Phone:916-452-8105
Practice Address - Fax:916-452-4659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0095580Medicaid
CAZZZ27355ZMedicare PIN
CAGR0095580Medicaid