Provider Demographics
NPI:1942420120
Name:SUN CITY VISION CLINIC
Entity Type:Organization
Organization Name:SUN CITY VISION CLINIC
Other - Org Name:SUN CITY VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:G
Authorized Official - Last Name:SHAW-MC MINN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:951-672-4971
Mailing Address - Street 1:27830 BRADLEY RD.
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586
Mailing Address - Country:US
Mailing Address - Phone:951-672-4971
Mailing Address - Fax:951-672-4083
Practice Address - Street 1:27830 BRADLEY RD.
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-2201
Practice Address - Country:US
Practice Address - Phone:951-672-4971
Practice Address - Fax:951-672-4083
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUN CITY VISION CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-27
Last Update Date:2008-09-11
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
CAZZZ81412ZMedicaid
CAZZZ81412ZMedicare ID - Type UnspecifiedOWNERS ID NUMBER
CAZZZ81412ZMedicare PIN
CAZZZ81412ZMedicaid