Provider Demographics
NPI:1508010463
Name:IMPERIAL VALLEY OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:IMPERIAL VALLEY OPTOMETRIC CORPORATION
Other - Org Name:OPTOM-EYES VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST/VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAY
Authorized Official - Middle Name:C
Authorized Official - Last Name:TAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-336-3003
Mailing Address - Street 1:525 W MAIN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-7900
Mailing Address - Country:US
Mailing Address - Phone:760-336-0010
Mailing Address - Fax:
Practice Address - Street 1:1503 N IMPERIAL AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-6301
Practice Address - Country:US
Practice Address - Phone:760-336-0010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA11960T152W00000X
CACA11166T152W00000X
CACA11368T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty