Provider Demographics
NPI:1407917701
Name:MARINA EYECARE CENTER
Entity Type:Organization
Organization Name:MARINA EYECARE CENTER
Other - Org Name:PACIFIC EYECARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:MATSUMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-390-6287
Mailing Address - Street 1:12461 W WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-5511
Mailing Address - Country:US
Mailing Address - Phone:310-390-6287
Mailing Address - Fax:310-391-8464
Practice Address - Street 1:12461 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5511
Practice Address - Country:US
Practice Address - Phone:310-390-6287
Practice Address - Fax:310-391-8464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7001T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWY5748Medicare PIN