Provider Demographics
NPI:1659388700
Name:EYE MEDICAL CLINIC OF FRESNO, INC.
Entity Type:Organization
Organization Name:EYE MEDICAL CLINIC OF FRESNO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-449-5097
Mailing Address - Street 1:1122 S STREET
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721
Mailing Address - Country:US
Mailing Address - Phone:559-449-5097
Mailing Address - Fax:559-439-6804
Practice Address - Street 1:1122 S STREET
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721
Practice Address - Country:US
Practice Address - Phone:559-449-5097
Practice Address - Fax:559-439-6804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ49159ZMedicaid
CAZZZ49159ZMedicare PIN
CACI3011Medicare PIN
CAZZZ49159ZMedicaid