Provider Demographics
NPI:1699201087
Name:VISUALLY SOUND OPTOMETRY
Entity Type:Organization
Organization Name:VISUALLY SOUND OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAVRICEK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:916-985-6399
Mailing Address - Street 1:2920 COLD SPRINGS RD STE B
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-4236
Mailing Address - Country:US
Mailing Address - Phone:530-626-7460
Mailing Address - Fax:916-985-0601
Practice Address - Street 1:410 PALLADIO PKWY
Practice Address - Street 2:1625
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-8828
Practice Address - Country:US
Practice Address - Phone:916-985-6399
Practice Address - Fax:916-985-0601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-04
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5233TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0052330Medicare UPIN