Provider Demographics
NPI:1164641577
Name:GUMM'S OPTICAL SHOPPE INC.
Entity Type:Organization
Organization Name:GUMM'S OPTICAL SHOPPE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DISPENSING OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-527-2510
Mailing Address - Street 1:910 MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-2735
Mailing Address - Country:US
Mailing Address - Phone:530-527-2510
Mailing Address - Fax:530-529-1150
Practice Address - Street 1:910 MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-2735
Practice Address - Country:US
Practice Address - Phone:530-527-2510
Practice Address - Fax:530-529-1150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD 1940332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0757470001OtherSUPPLIER
0757470001Medicare NSC