Provider Demographics
NPI:1912184359
Name:WOODCREST VISION CENTER
Entity Type:Organization
Organization Name:WOODCREST VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW- MCMINN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:951-780-0270
Mailing Address - Street 1:17675 VAN BUREN BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-6076
Mailing Address - Country:US
Mailing Address - Phone:951-780-0270
Mailing Address - Fax:951-780-4807
Practice Address - Street 1:17675 VAN BUREN BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-6076
Practice Address - Country:US
Practice Address - Phone:951-780-0270
Practice Address - Fax:951-780-4807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6553T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0065530Medicaid
CAZZZ95800ZMedicare PIN