Provider Demographics
NPI:1871738971
Name:EYE CARE FOR DIABETICS MEDICAL GROUP, INC
Entity type:Organization
Organization Name:EYE CARE FOR DIABETICS MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:W
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:310-671-0909
Mailing Address - Street 1:323 N PRAIRIE AVE
Mailing Address - Street 2:SUITE 217
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4502
Mailing Address - Country:US
Mailing Address - Phone:310-671-0909
Mailing Address - Fax:310-412-0066
Practice Address - Street 1:323 N PRAIRIE AVE
Practice Address - Street 2:SUITE 217
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4502
Practice Address - Country:US
Practice Address - Phone:310-671-0909
Practice Address - Fax:310-412-0066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30576302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1083813380Medicare UPIN