Provider Demographics
NPI:1609247279
Name:PRIME OPTICAL
Entity Type:Organization
Organization Name:PRIME OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIANO
Authorized Official - Middle Name:
Authorized Official - Last Name:SALCEDO
Authorized Official - Suffix:
Authorized Official - Credentials:RDO
Authorized Official - Phone:909-888-8700
Mailing Address - Street 1:407 E GILBERT ST
Mailing Address - Street 2:SUITE # 10
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5325
Mailing Address - Country:US
Mailing Address - Phone:909-888-8700
Mailing Address - Fax:909-888-8710
Practice Address - Street 1:407 E GILBERT ST
Practice Address - Street 2:SUITE # 10
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5325
Practice Address - Country:US
Practice Address - Phone:909-888-8700
Practice Address - Fax:909-888-8710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL40434332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8005541312OtherEIN