Provider Demographics
NPI:1740409648
Name:TRACY OPTOMETRY GROUP, INC
Entity Type:Organization
Organization Name:TRACY OPTOMETRY GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:MOLINE
Authorized Official - Suffix:
Authorized Official - Credentials:0D
Authorized Official - Phone:209-835-7446
Mailing Address - Street 1:36 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3902
Mailing Address - Country:US
Mailing Address - Phone:209-835-7446
Mailing Address - Fax:209-835-3572
Practice Address - Street 1:36 W 10TH ST
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3902
Practice Address - Country:US
Practice Address - Phone:209-835-7446
Practice Address - Fax:209-835-3572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACOR1056152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD005210Medicaid
CAZZZ31017ZMedicare PIN
CA5482220001Medicare NSC