Provider Demographics
NPI:1568494649
Name:EYECARE SPECIALISTS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:EYECARE SPECIALISTS MEDICAL GROUP, INC.
Other - Org Name:ATLANTIS EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:FELISA
Authorized Official - Middle Name:MARISOL
Authorized Official - Last Name:GALINDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-305-9100
Mailing Address - Street 1:2571 W. LA PALMA AVE.
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801
Mailing Address - Country:US
Mailing Address - Phone:714-821-4666
Mailing Address - Fax:714-826-2300
Practice Address - Street 1:8028 3RD ST
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3602
Practice Address - Country:US
Practice Address - Phone:562-622-8700
Practice Address - Fax:562-622-1800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAW14969A152W00000X, 207W00000X
152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14969AOtherGROUP NUMBER
CAW14969AOtherGROUP NUMBER
4649360004Medicare NSC