Provider Demographics
NPI:1457756363
Name:EYEXAM OF CA
Entity Type:Organization
Organization Name:EYEXAM OF CA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR OF EYEXAM OF CA
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:TEDDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-217-2974
Mailing Address - Street 1:11751 RANCHITO ST
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91732-1317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 GLENDALE GALLERIA
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91210-1301
Practice Address - Country:US
Practice Address - Phone:818-552-4440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15134302R00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization