Provider Demographics
NPI:1326302316
Name:DR. SKINNER OPTOMETRY P.C.
Entity Type:Organization
Organization Name:DR. SKINNER OPTOMETRY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LOWREY
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-822-1115
Mailing Address - Street 1:PO BOX 2200
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92334-2200
Mailing Address - Country:US
Mailing Address - Phone:909-822-1115
Mailing Address - Fax:909-822-6346
Practice Address - Street 1:8275 SIERRA AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3557
Practice Address - Country:US
Practice Address - Phone:909-822-1115
Practice Address - Fax:909-822-6346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9363T261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center