Provider Demographics
NPI:1023378635
Name:VISION DYNAMICS OPTOMETRIC CENTER
Entity type:Organization
Organization Name:VISION DYNAMICS OPTOMETRIC CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:S
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:925-838-3021
Mailing Address - Street 1:1480 MORAGA RD
Mailing Address - Street 2:SUITE I - 222
Mailing Address - City:MORAGA
Mailing Address - State:CA
Mailing Address - Zip Code:94556-2005
Mailing Address - Country:US
Mailing Address - Phone:415-786-4521
Mailing Address - Fax:206-426-7275
Practice Address - Street 1:417 SYCAMORE VALLEY ROAD WEST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526
Practice Address - Country:US
Practice Address - Phone:925-838-3021
Practice Address - Fax:925-838-9068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA007869152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD118530Medicare UPIN
CASD118530Medicare PIN