Provider Demographics
NPI:1710185459
Name:HENLEY OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:HENLEY OPTOMETRIC CORPORATION
Other - Org Name:UPLAND EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HENLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-982-0900
Mailing Address - Street 1:876 N MOUNTAIN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4166
Mailing Address - Country:US
Mailing Address - Phone:909-982-0900
Mailing Address - Fax:909-982-7657
Practice Address - Street 1:876 N MOUNTAIN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4166
Practice Address - Country:US
Practice Address - Phone:909-982-0900
Practice Address - Fax:909-982-7657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10246T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4864910001Medicare NSC
CAZZZ28614ZMedicare PIN