Provider Demographics
NPI:1245517804
Name:RUSSELL R SLAUGH OD AN OPTOMETRIC CORPORATION
Entity type:Organization
Organization Name:RUSSELL R SLAUGH OD AN OPTOMETRIC CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:R
Authorized Official - Last Name:SLAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-228-2020
Mailing Address - Street 1:56970 YUCCA TRL
Mailing Address - Street 2:STE 101
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-7910
Mailing Address - Country:US
Mailing Address - Phone:760-228-2020
Mailing Address - Fax:760-369-2020
Practice Address - Street 1:56970 YUCCA TRL
Practice Address - Street 2:STE 101
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-7910
Practice Address - Country:US
Practice Address - Phone:760-228-2020
Practice Address - Fax:760-369-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-10
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14240152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1245517804OtherGROUP NPI
CA1659684751OtherRUSSELL R SLAUGH O.D.
CA1134103484OtherDENNIS G. LOWMAN O.D.
1770922395OtherNPI
CAZZZ696612OtherBLUE SHIELD
CASD0142400OtherBLUE SHIELD
1770922395OtherNPI
CA1659684751OtherRUSSELL R SLAUGH O.D.
CA1245517804OtherGROUP NPI
CASD0142400OtherBLUE SHIELD
CADT4695Medicare PIN
CAFK688YMedicare PIN
CAGA464ZMedicare PIN
CA1134103484OtherDENNIS G. LOWMAN O.D.
CAGA464ZMedicare PIN