Provider Demographics
NPI:1437636255
Name:JACQUELINE M. CULLINANE,O.D. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JACQUELINE M. CULLINANE,O.D. A PROFESSIONAL CORPORATION
Other - Org Name:JACQUELINE M. CULLINANE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:BIEDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-581-6880
Mailing Address - Street 1:22741 LAMBERT ST STE 1601
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1617
Mailing Address - Country:US
Mailing Address - Phone:949-581-6880
Mailing Address - Fax:949-581-1341
Practice Address - Street 1:22741 LAMBERT ST STE 1601
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1617
Practice Address - Country:US
Practice Address - Phone:949-581-6880
Practice Address - Fax:949-581-1341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-24
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10306TPG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty