Provider Demographics
NPI:1578869004
Name:EYE-MATE OPTICAL
Entity Type:Organization
Organization Name:EYE-MATE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:R
Authorized Official - Middle Name:MENDOZA
Authorized Official - Last Name:FAJARDO
Authorized Official - Suffix:
Authorized Official - Credentials:RSLD, RCLD
Authorized Official - Phone:213-380-3836
Mailing Address - Street 1:4214 BEVERLY BLVD
Mailing Address - Street 2:ROOM 207
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-4479
Mailing Address - Country:US
Mailing Address - Phone:213-380-3836
Mailing Address - Fax:213-380-3836
Practice Address - Street 1:4214 BEVERLY BLVD
Practice Address - Street 2:ROOM 207
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-4479
Practice Address - Country:US
Practice Address - Phone:213-380-3836
Practice Address - Fax:213-380-3836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-01
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD3788156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty