Provider Demographics
NPI:1457423501
Name:MATTHEW R HILEMAN, O D A PROFESIONAL CORPORATION
Entity Type:Organization
Organization Name:MATTHEW R HILEMAN, O D A PROFESIONAL CORPORATION
Other - Org Name:ST. HELENA OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:HILEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:707-963-7923
Mailing Address - Street 1:1104 ADAMS ST
Mailing Address - Street 2:STE 101
Mailing Address - City:SAINT HELENA
Mailing Address - State:CA
Mailing Address - Zip Code:94574-1164
Mailing Address - Country:US
Mailing Address - Phone:707-963-7923
Mailing Address - Fax:
Practice Address - Street 1:1104 ADAMS ST
Practice Address - Street 2:STE 101
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-1164
Practice Address - Country:US
Practice Address - Phone:707-963-7923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11888T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ27893ZMedicare PIN
CA5154980001Medicare NSC