Provider Demographics
NPI:1891415410
Name:MODESTO OPTOMETRIC VISION CENTER INC A PROFESSIONAL OPTOMETRIC CORP
Entity Type:Organization
Organization Name:MODESTO OPTOMETRIC VISION CENTER INC A PROFESSIONAL OPTOMETRIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-869-3300
Mailing Address - Street 1:3601 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1161
Mailing Address - Country:US
Mailing Address - Phone:209-521-1028
Mailing Address - Fax:209-521-7488
Practice Address - Street 1:3601 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1161
Practice Address - Country:US
Practice Address - Phone:209-521-1028
Practice Address - Fax:209-521-7488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-01
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty