Provider Demographics
NPI:1497866545
Name:THREE RIVERS OPTOMETRIC GRP INC
Entity Type:Organization
Organization Name:THREE RIVERS OPTOMETRIC GRP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:TAXERA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:530-674-5273
Mailing Address - Street 1:1245 THARP RD
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95993
Mailing Address - Country:US
Mailing Address - Phone:530-674-5273
Mailing Address - Fax:530-674-5275
Practice Address - Street 1:1245 THARP RD
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95993
Practice Address - Country:US
Practice Address - Phone:530-674-5273
Practice Address - Fax:530-674-5275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7072T152W00000X
CA7125T152W00000X
CA12712T152W00000X
CACOR949152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD004280Medicaid
CA4598980001OtherMEDICARE CIGNA
CAZZZ078052OtherBS
CK6935OtherRAILROAD MCARE
CAGSD004280Medicaid
CAZZZ23333ZMedicare PIN