Basic Information
| Provider Information | |||||||||
| NPI: | 1932612702 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MICHELLE TIMENOVICH O.D., A PROFESSIONAL OPTOMETRY CORP. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WINE COUNTRY EYECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9367 RIBERENA CIR | ||||||||
| Address2: | |||||||||
| City: | ATASCADERO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934226252 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 180 NIBLICK RD | ||||||||
| Address2: | |||||||||
| City: | PASO ROBLES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934464842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052370275 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2017 | ||||||||
| LastUpdateDate: | 01/04/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TIMENOVICH | ||||||||
| AuthorizedOfficialFirstName: | MICHELINA | ||||||||
| AuthorizedOfficialMiddleName: | LILLIAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST/SUBLEASE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8184303336 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 14961TLG | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.