Provider Demographics
NPI:1457396871
Name:MARY L. DEMOSS O.D. INC.
Entity Type:Organization
Organization Name:MARY L. DEMOSS O.D. INC.
Other - Org Name:CANYON LAKE VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LUCINDA
Authorized Official - Last Name:DEMOSS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:951-244-4444
Mailing Address - Street 1:31722 RAILROAD CANYON RD
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-9486
Mailing Address - Country:US
Mailing Address - Phone:951-244-4444
Mailing Address - Fax:951-244-1414
Practice Address - Street 1:31722 RAILROAD CANYON RD
Practice Address - Street 2:
Practice Address - City:CANYON LAKE
Practice Address - State:CA
Practice Address - Zip Code:92587-9486
Practice Address - Country:US
Practice Address - Phone:951-244-4444
Practice Address - Fax:951-244-1414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8955152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD004910Medicaid
CAAPPLIED FORMedicare ID - Type Unspecified