Provider Demographics
NPI:1841526852
Name:ELITE EYE CARE OPTOMETRY GROUP
Entity type:Organization
Organization Name:ELITE EYE CARE OPTOMETRY GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:T
Authorized Official - Last Name:KOO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:408-777-9000
Mailing Address - Street 1:20568 STEVENS CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-2130
Mailing Address - Country:US
Mailing Address - Phone:408-777-9000
Mailing Address - Fax:408-777-9009
Practice Address - Street 1:20568 STEVENS CREEK BLVD
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-2130
Practice Address - Country:US
Practice Address - Phone:408-777-9000
Practice Address - Fax:408-777-9009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-26
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13260T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty