Provider Demographics
NPI:1639426273
Name:GREENHAVEN OPTOMETRY
Entity Type:Organization
Organization Name:GREENHAVEN OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:OMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:916-421-1278
Mailing Address - Street 1:7410 GREENHAVEN DRIVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-5165
Mailing Address - Country:US
Mailing Address - Phone:916-421-1278
Mailing Address - Fax:916-421-5055
Practice Address - Street 1:7410 GREENHAVEN DRIVE
Practice Address - Street 2:SUITE 140
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95831-5165
Practice Address - Country:US
Practice Address - Phone:916-421-1278
Practice Address - Fax:916-421-5055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-14
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA OPT 6310 TPL152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHC543AMedicare PIN