Provider Demographics
NPI:1750991220
Name:PACK, ALYSSA TERESA
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:TERESA
Last Name:PACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 MANSIONES LN
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-7914
Mailing Address - Country:US
Mailing Address - Phone:619-632-7332
Mailing Address - Fax:
Practice Address - Street 1:890 EASTLAKE PKWY STE 102
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-4521
Practice Address - Country:US
Practice Address - Phone:619-216-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-08
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34608152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist