Provider Demographics
NPI:1891939922
Name:EDMOND BETMALECK, OD , AN OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:EDMOND BETMALECK, OD , AN OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:BETMALECK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:661-799-7464
Mailing Address - Street 1:24305 TOWN CENTER DR
Mailing Address - Street 2:SUITE 160
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-1307
Mailing Address - Country:US
Mailing Address - Phone:661-799-7464
Mailing Address - Fax:661-799-7583
Practice Address - Street 1:24305 TOWN CENTER DR
Practice Address - Street 2:SUITE 160
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-1307
Practice Address - Country:US
Practice Address - Phone:661-799-7464
Practice Address - Fax:661-799-7583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10286T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU53204Medicare UPIN
CAOP10286Medicare PIN