Provider Demographics
NPI:1477636264
Name:BEACH VISION CENTER, AN OPTOMETRY CORPORATION
Entity Type:Organization
Organization Name:BEACH VISION CENTER, AN OPTOMETRY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:A.
Authorized Official - Middle Name:CORY
Authorized Official - Last Name:THIES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:562-431-1301
Mailing Address - Street 1:10900 LOS ALAMITOS BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2354
Mailing Address - Country:US
Mailing Address - Phone:562-431-1301
Mailing Address - Fax:562-594-0624
Practice Address - Street 1:10900 LOS ALAMITOS BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2354
Practice Address - Country:US
Practice Address - Phone:562-431-1301
Practice Address - Fax:562-594-0624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA07859T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWY099Medicare PIN
CAT70232Medicare UPIN
CAWOP7859AMedicare ID - Type Unspecified
CAT70020Medicare UPIN
CAWOP5408HMedicare ID - Type Unspecified