Provider Demographics
NPI:1952477416
Name:EYE SPY VISION CARE OPTOMETRY, INC
Entity Type:Organization
Organization Name:EYE SPY VISION CARE OPTOMETRY, INC
Other - Org Name:EYE SPY VISION CARE OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MAHAPHON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:707-253-7111
Mailing Address - Street 1:2291 SOSCOL AVE
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-3620
Mailing Address - Country:US
Mailing Address - Phone:707-253-7111
Mailing Address - Fax:707-253-7192
Practice Address - Street 1:2291 SOSCOL AVE
Practice Address - Street 2:SUITE B
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-3620
Practice Address - Country:US
Practice Address - Phone:707-253-7111
Practice Address - Fax:707-253-7192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 12138 TPA152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1003918012OtherNPI INDIVIDUAL DOCTOR
CA1003918012OtherNPI INDIVIDUAL DOCTOR