Provider Demographics
NPI:1801949755
Name:EYE SIGHT OPTICIAN, INC.
Entity type:Organization
Organization Name:EYE SIGHT OPTICIAN, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN OWNER CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FOULADIAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNAO OPTICIAN
Authorized Official - Phone:310-545-4090
Mailing Address - Street 1:223 MANHATTAN BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266
Mailing Address - Country:US
Mailing Address - Phone:310-545-4090
Mailing Address - Fax:310-545-2252
Practice Address - Street 1:223 MANHATTAN BEACH BLVD
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266
Practice Address - Country:US
Practice Address - Phone:310-545-4090
Practice Address - Fax:310-545-2252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACL102156FX1800X
CASL198156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA222831472Medicaid
CASRYAB16680406000OtherRESALE NUMBER
CASRYAB16680406000OtherRESALE NUMBER
CA222831472Medicaid