Provider Demographics
NPI:1255514642
Name:EYEDENTITY VISION OPTOMETRY, INC.
Entity type:Organization
Organization Name:EYEDENTITY VISION OPTOMETRY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:415-334-2020
Mailing Address - Street 1:2786 DIAMOND ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94131-3057
Mailing Address - Country:US
Mailing Address - Phone:415-334-2020
Mailing Address - Fax:415-681-9268
Practice Address - Street 1:2786 DIAMOND ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94131-3057
Practice Address - Country:US
Practice Address - Phone:415-334-2020
Practice Address - Fax:415-681-9268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-09
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12604261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0126040Medicare PIN
CAV00225Medicare UPIN