Provider Demographics
NPI:1578162640
Name:BEAR CREEK EYE CARE OPTOMETRY
Entity Type:Organization
Organization Name:BEAR CREEK EYE CARE OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-609-9099
Mailing Address - Street 1:36330 HIDDEN SPRINGS RD STE A
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-5804
Mailing Address - Country:US
Mailing Address - Phone:951-609-9099
Mailing Address - Fax:
Practice Address - Street 1:36330 HIDDEN SPRINGS RD STE A
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-5804
Practice Address - Country:US
Practice Address - Phone:951-609-9099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7216142Medicaid