Provider Demographics
NPI:1508056102
Name:GARY SNEAG OD OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:GARY SNEAG OD OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SNEAG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:858-560-5181
Mailing Address - Street 1:4310 GENESEE AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-4970
Mailing Address - Country:US
Mailing Address - Phone:858-560-5181
Mailing Address - Fax:858-560-1926
Practice Address - Street 1:4310 GENESEE AVE
Practice Address - Street 2:STE 101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-4970
Practice Address - Country:US
Practice Address - Phone:858-560-5181
Practice Address - Fax:858-560-1926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 8399152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0827300001Medicare NSC
CAW19652Medicare PIN