Provider Demographics
NPI:1225256977
Name:EYE MEDICAL CLINIC OF SANTA CLARA VALLEY
Entity Type:Organization
Organization Name:EYE MEDICAL CLINIC OF SANTA CLARA VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COTTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-869-3400
Mailing Address - Street 1:220 MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-2903
Mailing Address - Country:US
Mailing Address - Phone:408-869-3400
Mailing Address - Fax:
Practice Address - Street 1:220 MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-2903
Practice Address - Country:US
Practice Address - Phone:408-869-3401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA000G93010332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0634540001Medicare NSC