Provider Demographics
NPI:1780743153
Name:SOUTH COUNTY EYE CARE OPTOMETRIC GROUP
Entity type:Organization
Organization Name:SOUTH COUNTY EYE CARE OPTOMETRIC GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DEANA
Authorized Official - Middle Name:HARDY
Authorized Official - Last Name:WEEMS
Authorized Official - Suffix:
Authorized Official - Credentials:ABO, NCLE
Authorized Official - Phone:949-454-1064
Mailing Address - Street 1:23002 LAKE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-6801
Mailing Address - Country:US
Mailing Address - Phone:949-454-1064
Mailing Address - Fax:
Practice Address - Street 1:23002 LAKE CENTER DR
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-6801
Practice Address - Country:US
Practice Address - Phone:949-454-1064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACOR 1085152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19485Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER