Provider Demographics
NPI:1568651156
Name:EXCEL EYECARE OPTOMETRY
Entity Type:Organization
Organization Name:EXCEL EYECARE OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:AI-DONG
Authorized Official - Last Name:GAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:858-780-9889
Mailing Address - Street 1:9975 CARMEL MOUNTAIN RD STE G6
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-2800
Mailing Address - Country:US
Mailing Address - Phone:858-780-9889
Mailing Address - Fax:858-780-9876
Practice Address - Street 1:9975 CARMEL MOUNTAIN RD STE G6
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-2800
Practice Address - Country:US
Practice Address - Phone:858-780-9889
Practice Address - Fax:858-780-9876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP 3379152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABT023AMedicare PIN