Provider Demographics
NPI:1922003821
Name:SISKIYOU OPTICAL
Entity Type:Organization
Organization Name:SISKIYOU OPTICAL
Other - Org Name:YREKA OPTICAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BELMIRA
Authorized Official - Middle Name:PARDAL
Authorized Official - Last Name:BORG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-842-2760
Mailing Address - Street 1:2524 WESTSIDE RD
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-9129
Mailing Address - Country:US
Mailing Address - Phone:530-842-2760
Mailing Address - Fax:530-842-5839
Practice Address - Street 1:2524 WESTSIDE RD
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-9129
Practice Address - Country:US
Practice Address - Phone:530-842-2760
Practice Address - Fax:530-842-5839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR001121000 00OtherBLUE CROSS/BLUE SHIELD
OR001121000 00OtherBLUE CROSS/BLUE SHIELD