Provider Demographics
NPI:1669697348
Name:SHASTA VISION GROUP AN OPTOMETRIC CORPORATION
Entity type:Organization
Organization Name:SHASTA VISION GROUP AN OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNELLE
Authorized Official - Middle Name:G
Authorized Official - Last Name:MAYGREN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:530-926-2033
Mailing Address - Street 1:110 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2209
Mailing Address - Country:US
Mailing Address - Phone:530-926-2033
Mailing Address - Fax:530-926-3722
Practice Address - Street 1:110 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067
Practice Address - Country:US
Practice Address - Phone:530-926-2033
Practice Address - Fax:530-926-3722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152W00000X152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0319220001Medicare NSC
CAZZZ16921ZMedicare PIN