Provider Demographics
NPI:1174708804
Name:EAGLE VISION EYE CARE OPTOMETRIC GROUP
Entity type:Organization
Organization Name:EAGLE VISION EYE CARE OPTOMETRIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:916-231-0034
Mailing Address - Street 1:5777 GREENBACK LN.
Mailing Address - Street 2:STE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841-2013
Mailing Address - Country:US
Mailing Address - Phone:916-231-0034
Mailing Address - Fax:916-231-0038
Practice Address - Street 1:5777 GREENBACK LN.
Practice Address - Street 2:STE 100
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-2013
Practice Address - Country:US
Practice Address - Phone:916-231-0034
Practice Address - Fax:916-231-0038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACT764AMedicaid
CA6383190001Medicare NSC
CACT764AMedicare PIN