Provider Demographics
NPI:1871769950
Name:FOLSOM OPTOMETRY CENTER
Entity type:Organization
Organization Name:FOLSOM OPTOMETRY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:LARRANCE
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-983-1066
Mailing Address - Street 1:1115 E BIDWELL ST STE 124
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-5554
Mailing Address - Country:US
Mailing Address - Phone:916-983-1066
Mailing Address - Fax:916-984-6922
Practice Address - Street 1:1115 E BIDWELL ST STE 124
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-5554
Practice Address - Country:US
Practice Address - Phone:916-983-1066
Practice Address - Fax:916-984-6922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6725T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU20304Medicare UPIN