Provider Demographics
NPI:1295860187
Name:DR HARVEY LEDESMA OPTOMETRY INC
Entity Type:Organization
Organization Name:DR HARVEY LEDESMA OPTOMETRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:HARVEY
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:LEDESMA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-793-5565
Mailing Address - Street 1:490 ALABAMA ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8089
Mailing Address - Country:US
Mailing Address - Phone:909-793-5565
Mailing Address - Fax:909-793-5575
Practice Address - Street 1:490 ALABAMA ST
Practice Address - Street 2:SUITE 107
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8089
Practice Address - Country:US
Practice Address - Phone:909-793-5565
Practice Address - Fax:909-793-5575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACAOPT12094TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ05779ZMedicare PIN