Provider Demographics
NPI:1154634236
Name:FAMILY OPTOMETRY OF TRACY INC
Entity Type:Organization
Organization Name:FAMILY OPTOMETRY OF TRACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORINNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SHELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-229-8611
Mailing Address - Street 1:2104 W GRANT LINE RD
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-7309
Mailing Address - Country:US
Mailing Address - Phone:209-229-8611
Mailing Address - Fax:209-229-8559
Practice Address - Street 1:2104 W GRANT LINE RD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-7309
Practice Address - Country:US
Practice Address - Phone:209-229-8611
Practice Address - Fax:209-229-8559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-19
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13351 TPL152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty