Provider Demographics
NPI:1508018748
Name:PARK AVENUE OPTOMETRY INC
Entity Type:Organization
Organization Name:PARK AVENUE OPTOMETRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUDOLPH
Authorized Official - Middle Name:GARCIA
Authorized Official - Last Name:ALANIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-622-3531
Mailing Address - Street 1:648 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-3621
Mailing Address - Country:US
Mailing Address - Phone:909-622-3531
Mailing Address - Fax:909-622-4897
Practice Address - Street 1:648 N PARK AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-3621
Practice Address - Country:US
Practice Address - Phone:909-622-3531
Practice Address - Fax:909-622-4897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 12788152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACW531AMedicare PIN