Provider Demographics
NPI:1407932619
Name:PACIFIC EYE INSTITUTE A MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PACIFIC EYE INSTITUTE A MEDICAL GROUP INC
Other - Org Name:PACIFIC EYE INSTITUTE AMBULATORY SURGERY CTR
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:DESALVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-982-8846
Mailing Address - Street 1:555 N 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4904
Mailing Address - Country:US
Mailing Address - Phone:909-982-8846
Mailing Address - Fax:909-931-0791
Practice Address - Street 1:555 N 13TH AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4904
Practice Address - Country:US
Practice Address - Phone:909-982-8846
Practice Address - Fax:909-931-0791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000525261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR51061FMedicaid
CAZZZ27062ZMedicare PIN
CASUR51061FMedicaid