Provider Demographics
NPI:1437117231
Name:ELITE EYECARE MEDICAL GROUP A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ELITE EYECARE MEDICAL GROUP A MEDICAL CORPORATION
Other - Org Name:KENDALL OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BYLSMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-925-2637
Mailing Address - Street 1:910 E STOWELL RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-7001
Mailing Address - Country:US
Mailing Address - Phone:805-925-2637
Mailing Address - Fax:805-347-0033
Practice Address - Street 1:425 W CENTRAL AVE STE 102
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436
Practice Address - Country:US
Practice Address - Phone:805-736-2020
Practice Address - Fax:805-737-1733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ61060ZOtherBLUE SHIELD OF CA
CAGR0086920Medicaid
CAGSD004611Medicaid
CAGR0086920Medicaid
CAGSD004611Medicaid