Provider Demographics
NPI:1780080994
Name:PACIFIC VISION CARE, OPTOMETRIC SERVICES, INC.
Entity type:Organization
Organization Name:PACIFIC VISION CARE, OPTOMETRIC SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:EN-PEI
Authorized Official - Last Name:WOO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:562-867-2020
Mailing Address - Street 1:5532 WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90713-1535
Mailing Address - Country:US
Mailing Address - Phone:562-867-2020
Mailing Address - Fax:562-867-6100
Practice Address - Street 1:5532 WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90713-1535
Practice Address - Country:US
Practice Address - Phone:562-867-2020
Practice Address - Fax:562-867-6100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-15
Last Update Date:2014-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11781TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0117810Medicaid
CA02-6308745OtherVSP
CA11781TLGOtherSTATE LICENSE
CA11934066OtherCAQH
CA02-6308745OtherVSP
CA11934066OtherCAQH