Provider Demographics
NPI:1932439304
Name:NICOLE JAE SIM OPTOMETRIC, INC
Entity Type:Organization
Organization Name:NICOLE JAE SIM OPTOMETRIC, INC
Other - Org Name:WALNUT SQUARE OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:JAE
Authorized Official - Last Name:SIM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:510-548-3947
Mailing Address - Street 1:2118 VINE ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1524
Mailing Address - Country:US
Mailing Address - Phone:510-548-3947
Mailing Address - Fax:510-548-3501
Practice Address - Street 1:2118 VINE ST
Practice Address - Street 2:SUITE E
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1524
Practice Address - Country:US
Practice Address - Phone:510-548-3947
Practice Address - Fax:510-548-3501
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NICOLE JAE SIM OPTOMETRIC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-07
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11438TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty