Provider Demographics
NPI:1619929890
Name:PAUL R. GOLLENDER, O.D.
Entity Type:Organization
Organization Name:PAUL R. GOLLENDER, O.D.
Other - Org Name:RENAISSANCE EYE, A PROFESSIONAL OPTOMETRY CORPORATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OPTOMETRIST/SHAREHOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:GOLLENDER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:916-786-8909
Mailing Address - Street 1:1263 PLEASANT GROVE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-5858
Mailing Address - Country:US
Mailing Address - Phone:916-786-8909
Mailing Address - Fax:916-773-1195
Practice Address - Street 1:1263 PLEASANT GROVE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-5858
Practice Address - Country:US
Practice Address - Phone:916-786-8909
Practice Address - Fax:916-773-1195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8998TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0089980Medicaid
CASD0089980Medicaid