Provider Demographics
NPI:1255702767
Name:SOLACE OPTOMETRY
Entity type:Organization
Organization Name:SOLACE OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:TAMPOYA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:951-296-7312
Mailing Address - Street 1:28039 SCOTT RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-7479
Mailing Address - Country:US
Mailing Address - Phone:951-301-3626
Mailing Address - Fax:951-301-8970
Practice Address - Street 1:28039 SCOTT RD
Practice Address - Street 2:SUITE F
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-7479
Practice Address - Country:US
Practice Address - Phone:951-301-3626
Practice Address - Fax:951-301-8970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-09
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13282152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADR0912Medicare UPIN