Provider Demographics
NPI:1598805269
Name:LEYBIN LAKESIDE OPTICAL
Entity Type:Organization
Organization Name:LEYBIN LAKESIDE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONID
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:LEYBIN
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:415-334-2022
Mailing Address - Street 1:2645 OCEAN AVE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94132-1633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2645 OCEAN AVE
Practice Address - Street 2:SUITE #2
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94132-1633
Practice Address - Country:US
Practice Address - Phone:415-334-2022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL799156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADX003943FMedicaid
CA=========OtherFEDERAL TAX ID
CA=========OtherFEDERAL TAX ID
CA0818490001Medicare UPIN