Provider Demographics
NPI:1528210531
Name:WAYNE C. SCHRADER, OPTOMETRIST, INC.
Entity Type:Organization
Organization Name:WAYNE C. SCHRADER, OPTOMETRIST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SCHRADER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:530-756-2481
Mailing Address - Street 1:1109 KENNEDY PL
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-1271
Mailing Address - Country:US
Mailing Address - Phone:530-756-2481
Mailing Address - Fax:530-756-3548
Practice Address - Street 1:1109 KENNEDY PL
Practice Address - Street 2:SUITE 1
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-1271
Practice Address - Country:US
Practice Address - Phone:530-756-2481
Practice Address - Fax:530-756-3548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5769152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6250740001Medicare NSC
CABR480AMedicare PIN