Provider Demographics
NPI:1740242445
Name:FOGG REMINGTON EYECARE, INC.
Entity Type:Organization
Organization Name:FOGG REMINGTON EYECARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MARCI
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-226-3973
Mailing Address - Street 1:1360 E HERNDON AVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3326
Mailing Address - Country:US
Mailing Address - Phone:559-449-5010
Mailing Address - Fax:559-449-5014
Practice Address - Street 1:40232 JUNCTION DR
Practice Address - Street 2:
Practice Address - City:OAKHURST
Practice Address - State:CA
Practice Address - Zip Code:93644-8719
Practice Address - Country:US
Practice Address - Phone:559-658-6402
Practice Address - Fax:559-658-6476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD004054Medicaid
CAGSD004054Medicaid