Provider Demographics
NPI:1881029577
Name:WAYNE HALSTROM OPTOMETRY, INC.
Entity Type:Organization
Organization Name:WAYNE HALSTROM OPTOMETRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:HALSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:510-791-2020
Mailing Address - Street 1:1123 NEWPARK MALL
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-5246
Mailing Address - Country:US
Mailing Address - Phone:510-791-2020
Mailing Address - Fax:
Practice Address - Street 1:1123 NEWPARK MALL
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-5246
Practice Address - Country:US
Practice Address - Phone:510-791-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5864TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty