Provider Demographics
NPI:1891826210
Name:APPLE VALLEY FAMILY OPTOMETRY CENTRE
Entity Type:Organization
Organization Name:APPLE VALLEY FAMILY OPTOMETRY CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:WALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-946-2700
Mailing Address - Street 1:15972 TUSCOLA RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2106
Mailing Address - Country:US
Mailing Address - Phone:760-946-2700
Mailing Address - Fax:760-946-3355
Practice Address - Street 1:15972 TUSCOLA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2106
Practice Address - Country:US
Practice Address - Phone:760-946-2700
Practice Address - Fax:760-946-3355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7082T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0070820Medicaid
CAZZZ05917ZOtherMEDICARE PTAN
CAZZZ58328ZOtherBLUE SHIELD
CAZZZ58328ZOtherBLUE SHIELD
CASD0070820Medicaid
CAZZZ05917ZOtherMEDICARE PTAN
CA=========OtherUNITED HEALTH CARE
CAZZZ05917ZOtherMEDICARE PTAN