Provider Demographics
NPI:1740300995
Name:DR. K.J.KOPECKO, O.D. AND DR. CHRISTINE L. MAYER, O.D., OPTOMETRY CORP
Entity type:Organization
Organization Name:DR. K.J.KOPECKO, O.D. AND DR. CHRISTINE L. MAYER, O.D., OPTOMETRY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:MAYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-643-8202
Mailing Address - Street 1:2623 SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-5712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2623 SPRINGS RD
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-5712
Practice Address - Country:US
Practice Address - Phone:707-643-8202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7004152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0022000Medicaid
CAZZZ29977ZMedicare PIN
CAGR0022000Medicaid