Provider Demographics
NPI:1598738999
Name:FALLESEN, BARRY L
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:L
Last Name:FALLESEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:GRIDLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95948-2215
Mailing Address - Country:US
Mailing Address - Phone:530-846-2697
Mailing Address - Fax:530-846-6426
Practice Address - Street 1:235 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:GRIDLEY
Practice Address - State:CA
Practice Address - Zip Code:95948
Practice Address - Country:US
Practice Address - Phone:530-846-2697
Practice Address - Fax:530-846-6426
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6911TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0870860001OtherCIGNA
CASD0069110Medicaid
SD0069110OtherM CARE
CASD0069110Medicaid
SD0069110OtherM CARE
CA5410490001Medicare NSC