Provider Demographics
NPI:1023094570
Name:OPTOMETRIC SPECIALTIES INC
Entity type:Organization
Organization Name:OPTOMETRIC SPECIALTIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:E
Authorized Official - Last Name:GAYLORD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:323-294-7517
Mailing Address - Street 1:3750 SANTA ROSALIA DR STE 102
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-3685
Mailing Address - Country:US
Mailing Address - Phone:323-294-7517
Mailing Address - Fax:
Practice Address - Street 1:3750 SANTA ROSALIA DR STE 102
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-3685
Practice Address - Country:US
Practice Address - Phone:323-294-7517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACOR 889332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD004160Medicaid
CAGSD004160Medicaid
WY163Medicare PIN
WY163Medicare PIN