Provider Demographics
NPI:1932612702
Name:MICHELLE TIMENOVICH O.D., A PROFESSIONAL OPTOMETRY CORP.
Entity Type:Organization
Organization Name:MICHELLE TIMENOVICH O.D., A PROFESSIONAL OPTOMETRY CORP.
Other - Org Name:WINE COUNTRY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST/SUBLEASE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELINA
Authorized Official - Middle Name:LILLIAN
Authorized Official - Last Name:TIMENOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:818-430-3336
Mailing Address - Street 1:9367 RIBERENA CIR
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-6252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 NIBLICK RD
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-4842
Practice Address - Country:US
Practice Address - Phone:805-237-0275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-14
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14961TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty