Provider Demographics
NPI:1568657278
Name:PROFESSIONAL EYECARE OPTOMETRY
Entity Type:Organization
Organization Name:PROFESSIONAL EYECARE OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIC ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAVODA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-376-2020
Mailing Address - Street 1:1030 COUNTRY CLUB DR STE A
Mailing Address - Street 2:
Mailing Address - City:MORAGA
Mailing Address - State:CA
Mailing Address - Zip Code:94556-1950
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1030 COUNTRY CLUB DR STE A
Practice Address - Street 2:
Practice Address - City:MORAGA
Practice Address - State:CA
Practice Address - Zip Code:94556-1950
Practice Address - Country:US
Practice Address - Phone:925-376-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6110152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ13949ZMedicare PIN
CA1228230001Medicare NSC