Provider Demographics
NPI:1619930955
Name:FOGG REMINGTON EYECARE, INC.
Entity Type:Organization
Organization Name:FOGG REMINGTON EYECARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:PENDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-449-5011
Mailing Address - Street 1:1360 E HERNDON AVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3326
Mailing Address - Country:US
Mailing Address - Phone:559-449-5010
Mailing Address - Fax:559-449-5010
Practice Address - Street 1:1360 E HERNDON AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3326
Practice Address - Country:US
Practice Address - Phone:559-449-5010
Practice Address - Fax:559-449-5010
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOGG REMINGTON EYECARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-08
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD004050Medicaid
CAZZZ13463ZMedicare ID - Type Unspecified