Provider Demographics
NPI:1932845559
Name:FOURTH OPTOMETRIC CARE OF CALIFORNIA
Entity Type:Organization
Organization Name:FOURTH OPTOMETRIC CARE OF CALIFORNIA
Other - Org Name:OPTOMETRY IN THE SQUARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:726-444-4545
Mailing Address - Street 1:3333 QUALITY DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7985
Mailing Address - Country:US
Mailing Address - Phone:704-712-0564
Mailing Address - Fax:
Practice Address - Street 1:4074 HARDWICK ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-2349
Practice Address - Country:US
Practice Address - Phone:562-633-6443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-06
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty