Provider Demographics
NPI:1164618682
Name:TACKETT, LAUREN REBECCA (OD)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:REBECCA
Last Name:TACKETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7605 MORRO RD
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-4433
Mailing Address - Country:US
Mailing Address - Phone:805-466-3777
Mailing Address - Fax:805-466-3700
Practice Address - Street 1:7605 MORRO RD
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-4433
Practice Address - Country:US
Practice Address - Phone:805-466-3777
Practice Address - Fax:805-466-3700
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13231T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0093530OtherBLUE SHIELD
CA5179480001Medicare NSC
CAWOP13231BMedicare PIN