Provider Demographics
NPI:1255342044
Name:ROBERT M THEAKER O D AN OPTOMETRIC CORPORATION
Entity type:Organization
Organization Name:ROBERT M THEAKER O D AN OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-637-5536
Mailing Address - Street 1:365 6TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-3834
Mailing Address - Country:US
Mailing Address - Phone:831-637-5536
Mailing Address - Fax:831-637-7601
Practice Address - Street 1:365 6TH ST
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-3834
Practice Address - Country:US
Practice Address - Phone:831-637-5536
Practice Address - Fax:831-637-7601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP 2359152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEK934AMedicare PIN
CADV4630Medicare PIN
CA6444110001Medicare NSC