Provider Demographics
NPI:1023238953
Name:SIEMS ADVANCED LASIK AND EYE CENTERS
Entity type:Organization
Organization Name:SIEMS ADVANCED LASIK AND EYE CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPHTHALMIC TECHNICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELPUSAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-718-2010
Mailing Address - Street 1:2121 E COAST HWY
Mailing Address - Street 2:STE 200
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-1931
Mailing Address - Country:US
Mailing Address - Phone:949-718-2010
Mailing Address - Fax:949-718-2011
Practice Address - Street 1:2121 E COAST HWY
Practice Address - Street 2:STE 200
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-1931
Practice Address - Country:US
Practice Address - Phone:949-718-2010
Practice Address - Fax:949-718-2011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8933T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2018998Medicaid
CA2018998Medicaid