Provider Demographics
NPI:1639515166
Name:R F CCOLLINS & S GOODMAN PTRS
Entity Type:Organization
Organization Name:R F CCOLLINS & S GOODMAN PTRS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OD
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-982-0076
Mailing Address - Street 1:5722 TELEPHONE RD
Mailing Address - Street 2:SUITE 19
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-5318
Mailing Address - Country:US
Mailing Address - Phone:818-982-0076
Mailing Address - Fax:
Practice Address - Street 1:5722 TELEPHONE RD
Practice Address - Street 2:SUITE 19
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-5318
Practice Address - Country:US
Practice Address - Phone:818-982-0076
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-10
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0082370Medicaid
CAHF391AMedicare PIN