Basic Information
| Provider Information | |||||||||
| NPI: | 1265515878 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMPIRE EYE AND LASER CENTER INC | ||||||||
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| OtherOrganizationName: | EMPIRE EYE AND LASER CENTER INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4101 EMPIRE DR | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933090681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613253937 | ||||||||
| FaxNumber: | 6612833937 | ||||||||
| Practice Location | |||||||||
| Address1: | 4101 EMPIRE DR | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933090681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613253937 | ||||||||
| FaxNumber: | 6612833937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 02/11/2013 | ||||||||
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| AuthorizedOfficialLastName: | SPARKS | ||||||||
| AuthorizedOfficialFirstName: | BRANDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MGR | ||||||||
| AuthorizedOfficialTelephone: | 6618692600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Z18298 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | GR0089910 | 05 | CA | MEDICAID |