Provider Demographics
NPI:1811224223
Name:BARRY L FALLESEN
Entity Type:Organization
Organization Name:BARRY L FALLESEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:FALLESEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-846-2697
Mailing Address - Street 1:235 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:GRIDLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95948-2215
Mailing Address - Country:US
Mailing Address - Phone:530-846-2697
Mailing Address - Fax:530-846-6426
Practice Address - Street 1:235 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:GRIDLEY
Practice Address - State:CA
Practice Address - Zip Code:95948-2215
Practice Address - Country:US
Practice Address - Phone:530-846-2697
Practice Address - Fax:530-846-6426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-05
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6911TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0069110Medicaid
CASD0069110Medicaid
CAT10438Medicare UPIN