Provider Demographics
NPI:1528002201
Name:MENDOCINO OPTICAL CO INC
Entity Type:Organization
Organization Name:MENDOCINO OPTICAL CO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:NIX
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:707-462-2744
Mailing Address - Street 1:280 S SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4828
Mailing Address - Country:US
Mailing Address - Phone:707-462-2744
Mailing Address - Fax:707-462-8789
Practice Address - Street 1:280 S SCHOOL ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4828
Practice Address - Country:US
Practice Address - Phone:707-462-2744
Practice Address - Fax:707-462-8789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA461332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADX003663F5Medicaid
CA1247OtherMESC BLUE SHIELD
CA0734050001Medicare NSC