Provider Demographics
NPI:1295588788
Name:SALLY HANSEN OD, INC.
Entity type:Organization
Organization Name:SALLY HANSEN OD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:805-235-0310
Mailing Address - Street 1:771 DOLLIVER ST REAR APT
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-2622
Mailing Address - Country:US
Mailing Address - Phone:805-235-0310
Mailing Address - Fax:
Practice Address - Street 1:411 TRAFFIC WAY STE D
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3362
Practice Address - Country:US
Practice Address - Phone:805-709-2433
Practice Address - Fax:805-855-4122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty