Provider Demographics
NPI:1467620062
Name:REDLANDS OPTOMETRY GROUP INC A PROFESSIONAL OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:REDLANDS OPTOMETRY GROUP INC A PROFESSIONAL OPTOMETRIC CORPORATION
Other - Org Name:REDLANDS OPTOMETRY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:KRISTINE
Authorized Official - Last Name:MATEJKAMCMORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-793-2106
Mailing Address - Street 1:1020 NEVADA ST
Mailing Address - Street 2:#202
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-2956
Mailing Address - Country:US
Mailing Address - Phone:909-793-2106
Mailing Address - Fax:909-792-3246
Practice Address - Street 1:1020 NEVADA ST
Practice Address - Street 2:#202
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2956
Practice Address - Country:US
Practice Address - Phone:909-793-2106
Practice Address - Fax:909-792-3246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11183T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABV333AMedicare UPIN
CABV333AMedicare PIN