Basic Information
| Provider Information | |||||||||
| NPI: | 1730168931 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KINGS EYE CENTER MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 W LACEY BLVD | ||||||||
| Address2: | |||||||||
| City: | HANFORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932305904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595853937 | ||||||||
| FaxNumber: | 5595823645 | ||||||||
| Practice Location | |||||||||
| Address1: | 1395 W LACEY BLVD | ||||||||
| Address2: | |||||||||
| City: | HANFORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932305904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595853937 | ||||||||
| FaxNumber: | 5595823645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2006 | ||||||||
| LastUpdateDate: | 06/06/2013 | ||||||||
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| AuthorizedOfficialLastName: | LEE-THOMAS | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5595853937 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | GR0091100 | 05 | CA | MEDICAID | GSD004060 | 05 | CA | MEDICAID | 490005146 | 01 | CA | RR MEDICARE | OTHER |