Provider Demographics
NPI:1922399864
Name:DOMINGUEZ ALDERSON OPTOMETRIC INC
Entity Type:Organization
Organization Name:DOMINGUEZ ALDERSON OPTOMETRIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:949-597-0104
Mailing Address - Street 1:21098 BAKE PKWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2163
Mailing Address - Country:US
Mailing Address - Phone:949-597-0104
Mailing Address - Fax:949-597-0106
Practice Address - Street 1:21098 BAKE PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2163
Practice Address - Country:US
Practice Address - Phone:949-597-0104
Practice Address - Fax:949-597-0106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGN407AMedicare PIN
CADU9274Medicare PIN