Provider Demographics
NPI:1770774457
Name:BIRD ROCK OPTICAL
Entity type:Organization
Organization Name:BIRD ROCK OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-427-2289
Mailing Address - Street 1:865 3RD AVE STE 121
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-1300
Mailing Address - Country:US
Mailing Address - Phone:619-427-2289
Mailing Address - Fax:619-426-3427
Practice Address - Street 1:865 3RD AVE STE 121
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1300
Practice Address - Country:US
Practice Address - Phone:619-427-2289
Practice Address - Fax:619-426-3427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA021264-06332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADX006044FMedicaid
CADX006044FMedicaid