Provider Demographics
NPI:1770559874
Name:JAMES R HENSLICK,O.D. PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JAMES R HENSLICK,O.D. PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER - PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HENSLICK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:949-643-2020
Mailing Address - Street 1:27451 LA PAZ RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-3739
Mailing Address - Country:US
Mailing Address - Phone:949-643-2020
Mailing Address - Fax:949-643-9061
Practice Address - Street 1:27451 LA PAZ RD
Practice Address - Street 2:SUITE B
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-3739
Practice Address - Country:US
Practice Address - Phone:949-643-2020
Practice Address - Fax:949-643-9061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 9009 TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18035Medicare PIN