Provider Demographics
NPI:1235598830
Name:ADVANCED EYECARE ASSOCIATES INC
Entity Type:Organization
Organization Name:ADVANCED EYECARE ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRAJAN
Authorized Official - Middle Name:JOAQUIN
Authorized Official - Last Name:SOARES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-826-1434
Mailing Address - Street 1:1028 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-4218
Mailing Address - Country:US
Mailing Address - Phone:209-826-1434
Mailing Address - Fax:
Practice Address - Street 1:1028 6TH ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4218
Practice Address - Country:US
Practice Address - Phone:209-826-1434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9569TPG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0095690Medicaid
CASD0095690Medicaid
CASD0095690Medicare PIN