Provider Demographics
NPI:1811023724
Name:ENTERPRISE OPTOMETRY GROUP
Entity Type:Organization
Organization Name:ENTERPRISE OPTOMETRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-222-3166
Mailing Address - Street 1:3080 VICTOR AVE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-1449
Mailing Address - Country:US
Mailing Address - Phone:530-222-3166
Mailing Address - Fax:530-222-6539
Practice Address - Street 1:3080 VICTOR AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-1449
Practice Address - Country:US
Practice Address - Phone:530-222-3166
Practice Address - Fax:530-222-6539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6443T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ71464YOtherBLUE SHIELD OF CALIFORNIA
CASD0064430Medicaid
CADP875AMedicare PIN
CAZZZ71464YOtherBLUE SHIELD OF CALIFORNIA