Provider Demographics
NPI:1790969236
Name:VANHOOSE & KIMBALL OPTOMETRIC CORP
Entity Type:Organization
Organization Name:VANHOOSE & KIMBALL OPTOMETRIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER OF CORP
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:W
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:858-453-4112
Mailing Address - Street 1:4575 LA JOLLA VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122
Mailing Address - Country:US
Mailing Address - Phone:858-453-4112
Mailing Address - Fax:858-453-4398
Practice Address - Street 1:4575 LA JOLLA VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1203
Practice Address - Country:US
Practice Address - Phone:858-453-4112
Practice Address - Fax:858-453-4398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6064-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0060642Medicaid
CASD0060642Medicaid