Provider Demographics
NPI:1710105846
Name:CLAREMONT OPTOMETRY GROUP
Entity Type:Organization
Organization Name:CLAREMONT OPTOMETRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BAGGARLY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-625-7861
Mailing Address - Street 1:695 W FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-3490
Mailing Address - Country:US
Mailing Address - Phone:909-625-7861
Mailing Address - Fax:909-621-0742
Practice Address - Street 1:695 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-3490
Practice Address - Country:US
Practice Address - Phone:909-625-7861
Practice Address - Fax:909-621-0742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9471-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU34034Medicare UPIN
CA0849310002Medicare NSC
CAU11114Medicare UPIN
CAWY040Medicare PIN