Provider Demographics
NPI:1477675387
Name:CENTRAL VALLEY EYE MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:CENTRAL VALLEY EYE MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:STEVENS
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-952-3700
Mailing Address - Street 1:36 W YOKUTS AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 COTTAGE AVE
Practice Address - Street 2:STE 102
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4935
Practice Address - Country:US
Practice Address - Phone:209-239-5303
Practice Address - Fax:209-239-0090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0076150Medicaid
1208550002Medicare NSC