Provider Demographics
NPI:1912203787
Name:SHANNON O. ALTURAS, O.D., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SHANNON O. ALTURAS, O.D., A PROFESSIONAL CORPORATION
Other - Org Name:EYEDEAL VISION OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:OLARIO
Authorized Official - Last Name:ALTURAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-539-3543
Mailing Address - Street 1:3658 S NOGALES ST
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-2714
Mailing Address - Country:US
Mailing Address - Phone:626-539-3543
Mailing Address - Fax:866-597-7977
Practice Address - Street 1:3658 S NOGALES ST
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-2714
Practice Address - Country:US
Practice Address - Phone:626-539-3543
Practice Address - Fax:866-597-7977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12898 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEJ599AMedicare PIN