Provider Demographics
NPI:1417135328
Name:CHICO OPTICAL DISPENSERS
Entity Type:Organization
Organization Name:CHICO OPTICAL DISPENSERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:JOHANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-895-1474
Mailing Address - Street 1:1722 MANGROVE AVE STE 32
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-2300
Mailing Address - Country:US
Mailing Address - Phone:530-895-1474
Mailing Address - Fax:530-895-1441
Practice Address - Street 1:1722 MANGROVE AVE STE 32
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-2300
Practice Address - Country:US
Practice Address - Phone:530-895-1474
Practice Address - Fax:530-895-1441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5327910001Medicare NSC