Provider Demographics
NPI:1790173508
Name:EYECARE SPECIALISTS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:EYECARE SPECIALISTS MEDICAL GROUP, INC.
Other - Org Name:ATLANTIS EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:FELISA
Authorized Official - Middle Name:MARISOL
Authorized Official - Last Name:GALINDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-305-9100
Mailing Address - Street 1:888 S DISNEYLAND DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-1847
Mailing Address - Country:US
Mailing Address - Phone:714-399-0678
Mailing Address - Fax:714-276-6489
Practice Address - Street 1:3655 LOMITA BLVD STE 410
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-1929
Practice Address - Country:US
Practice Address - Phone:310-803-9633
Practice Address - Fax:310-803-9634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-31
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68583152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty