Provider Demographics
NPI:1952774788
Name:SUN CITY VISION CLINIC OPTOMETRY
Entity type:Organization
Organization Name:SUN CITY VISION CLINIC OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LYSLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW-MCMINN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:951-990-7765
Mailing Address - Street 1:27830 BRADLEY RD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586-2201
Mailing Address - Country:US
Mailing Address - Phone:951-672-4971
Mailing Address - Fax:951-672-4083
Practice Address - Street 1:27830 BRADLEY RD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-2201
Practice Address - Country:US
Practice Address - Phone:951-672-4971
Practice Address - Fax:951-672-4083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT15133152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty