Provider Demographics
NPI:1326660960
Name:TROY HUMPHREYS OD FAAO, PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:TROY HUMPHREYS OD FAAO, PROFESSIONAL CORPORATION
Other - Org Name:LEGACY OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR OF OPTOMETRY
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HUMPHREYS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:530-257-4424
Mailing Address - Street 1:600 ASH ST
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-3714
Mailing Address - Country:US
Mailing Address - Phone:530-257-4424
Mailing Address - Fax:530-237-0426
Practice Address - Street 1:600 ASH ST
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-3714
Practice Address - Country:US
Practice Address - Phone:530-257-4424
Practice Address - Fax:530-237-0426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-16
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV33674OtherNORIDIAN
NV002516454Medicaid