Provider Demographics
NPI:1336262377
Name:CHRISTOPHER P. LIKENS & NANCY L. WILSON PTR
Entity Type:Organization
Organization Name:CHRISTOPHER P. LIKENS & NANCY L. WILSON PTR
Other - Org Name:WOODBRIDGE OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:LIKENS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:949-857-0676
Mailing Address - Street 1:4505 BARRANCA PKWY
Mailing Address - Street 2:#C
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-4707
Mailing Address - Country:US
Mailing Address - Phone:949-857-0676
Mailing Address - Fax:
Practice Address - Street 1:4505 BARRANCA PKWY
Practice Address - Street 2:#C
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4707
Practice Address - Country:US
Practice Address - Phone:949-857-0676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7839T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW20849Medicare PIN
CACK733ZMedicare PIN
CADQ5795Medicare PIN