Provider Demographics
NPI:1619099413
Name:CENTRAL VALLEY EYE MEDICAL GROUP
Entity Type:Organization
Organization Name:CENTRAL VALLEY EYE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:STEVENS
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-952-3700
Mailing Address - Street 1:36 W YOKUTS AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5713
Mailing Address - Country:US
Mailing Address - Phone:209-952-3700
Mailing Address - Fax:209-478-3302
Practice Address - Street 1:36 W YOKUTS AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5713
Practice Address - Country:US
Practice Address - Phone:209-952-3700
Practice Address - Fax:209-478-3302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0076150Medicaid