Provider Demographics
NPI:1780606673
Name:PARADIGM VISION CARE MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:PARADIGM VISION CARE MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:BENTON
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-673-2020
Mailing Address - Street 1:301 N PRAIRIE AVE
Mailing Address - Street 2:SUITE 601
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4507
Mailing Address - Country:US
Mailing Address - Phone:310-673-2020
Mailing Address - Fax:310-671-6785
Practice Address - Street 1:10300 COMPTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-3628
Practice Address - Country:US
Practice Address - Phone:310-673-2020
Practice Address - Fax:310-671-6785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID