Provider Demographics
NPI:1477760494
Name:EYES OF FAIRFIELD
Entity Type:Organization
Organization Name:EYES OF FAIRFIELD
Other - Org Name:SITE FOR SORE EYES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODAMARDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-421-2020
Mailing Address - Street 1:1350 TRAVIS BLVD
Mailing Address - Street 2:#1414 A
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-4646
Mailing Address - Country:US
Mailing Address - Phone:707-421-2020
Mailing Address - Fax:707-427-2313
Practice Address - Street 1:1350 TRAVIS BLVD
Practice Address - Street 2:#1414 A
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-4646
Practice Address - Country:US
Practice Address - Phone:707-421-2020
Practice Address - Fax:707-427-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90000946156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty