Provider Demographics
NPI:1013320472
Name:EOS EYECARE OPTOMETRIC GROUP
Entity Type:Organization
Organization Name:EOS EYECARE OPTOMETRIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:707-542-8883
Mailing Address - Street 1:2655 CLEVELAND AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2779
Mailing Address - Country:US
Mailing Address - Phone:707-542-8883
Mailing Address - Fax:707-546-7787
Practice Address - Street 1:2655 CLEVELAND AVE STE A
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2779
Practice Address - Country:US
Practice Address - Phone:707-542-8883
Practice Address - Fax:707-546-7787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-03
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11922TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA122547Medicare PIN