Provider Demographics
NPI:1619337110
Name:DR NIAM PHAN OD AN OPTOMETRY CORPORATION
Entity Type:Organization
Organization Name:DR NIAM PHAN OD AN OPTOMETRY CORPORATION
Other - Org Name:FOLSOM LAKE EYE CARE OPTOMETRIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-380-8145
Mailing Address - Street 1:4364 TOWN CENTER BLVD
Mailing Address - Street 2:STE 118
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762
Mailing Address - Country:US
Mailing Address - Phone:916-292-9226
Mailing Address - Fax:916-292-9227
Practice Address - Street 1:4364 TOWN CENTER BLVD STE 118
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-7127
Practice Address - Country:US
Practice Address - Phone:916-292-9226
Practice Address - Fax:916-292-9227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14181 TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA721630Medicare UPIN