Provider Demographics
NPI:1346235603
Name:SHASTA EYE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SHASTA EYE MEDICAL GROUP INC
Other - Org Name:LARKSPUR OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-377-6468
Mailing Address - Street 1:PO BOX 398986
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94139-5898
Mailing Address - Country:US
Mailing Address - Phone:530-223-2500
Mailing Address - Fax:530-226-1375
Practice Address - Street 1:3190 CHURN CREEK RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-2122
Practice Address - Country:US
Practice Address - Phone:530-223-2500
Practice Address - Fax:530-226-1375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0084930Medicaid
CAGR0084930Medicaid