Provider Demographics
NPI:1639367774
Name:GARY M. FREESTONE, OD, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:GARY M. FREESTONE, OD, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:MELVIN
Authorized Official - Last Name:FREESTONE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-875-1144
Mailing Address - Street 1:1850 N RIVERSIDE AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-8071
Mailing Address - Country:US
Mailing Address - Phone:909-875-1144
Mailing Address - Fax:909-875-0640
Practice Address - Street 1:1850 N RIVERSIDE AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-8071
Practice Address - Country:US
Practice Address - Phone:909-875-1144
Practice Address - Fax:909-875-0640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8983TPL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0089830Medicaid
CASD0089830Medicaid
CAZZZ06856ZMedicare PIN