Provider Demographics
NPI:1346548237
Name:APPLE VALLEY EYEWEAR, INC.
Entity Type:Organization
Organization Name:APPLE VALLEY EYEWEAR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:TANNER
Authorized Official - Last Name:ETCHELLS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-961-1919
Mailing Address - Street 1:13692 APPLE VALLEY RD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-4561
Mailing Address - Country:US
Mailing Address - Phone:760-961-1919
Mailing Address - Fax:760-961-1907
Practice Address - Street 1:13692 APPLE VALLEY RD
Practice Address - Street 2:SUITE 170
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-4561
Practice Address - Country:US
Practice Address - Phone:760-961-1919
Practice Address - Fax:760-961-1907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-02
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5518T332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0055181Medicaid
CAGQ888AMedicare PIN
CA6493090001Medicare NSC
CAT70035Medicare UPIN