Provider Demographics
NPI:1811266190
Name:LYNN M GILL
Entity type:Organization
Organization Name:LYNN M GILL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-966-3684
Mailing Address - Street 1:5284 HIGHWAY 49 NORTH
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MARIPOSA
Mailing Address - State:CA
Mailing Address - Zip Code:95338-9501
Mailing Address - Country:US
Mailing Address - Phone:209-966-3684
Mailing Address - Fax:209-966-3601
Practice Address - Street 1:5284 HIGHWAY 49 NORTH
Practice Address - Street 2:SUITE 1
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-9501
Practice Address - Country:US
Practice Address - Phone:209-966-3684
Practice Address - Fax:209-966-3601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-15
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152W00000X332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0051250Medicaid
CASD0051250Medicare PIN
CA0666060001Medicare NSC
CAT09876Medicare UPIN