Provider Demographics
NPI:1700381423
Name:EDMUNDO FIMBRES OD INC
Entity Type:Organization
Organization Name:EDMUNDO FIMBRES OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMUNDO
Authorized Official - Middle Name:
Authorized Official - Last Name:FIMBRES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:831-899-2020
Mailing Address - Street 1:915 HILBY AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:CA
Mailing Address - Zip Code:93955-5359
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:915 HILBY AVE STE 1
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955
Practice Address - Country:US
Practice Address - Phone:831-899-2020
Practice Address - Fax:831-899-5504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-26
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGROOO1660152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA152W00000XMedicaid