Provider Demographics
NPI:1609105451
Name:CALIFORNIA VISION AND VISAGE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CALIFORNIA VISION AND VISAGE MEDICAL GROUP INC
Other - Org Name:CALIFORNIA VISION AND VISAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HSU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-320-1902
Mailing Address - Street 1:18575 GALE AVE
Mailing Address - Street 2:SUITE 168
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91748-1340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18575 GALE AVE
Practice Address - Street 2:SUITE 168
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91748-1340
Practice Address - Country:US
Practice Address - Phone:773-320-1902
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty