Provider Demographics
NPI:1023286341
Name:TICE VALLEY OPTICAL
Entity type:Organization
Organization Name:TICE VALLEY OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:RDO
Authorized Official - Phone:925-935-6650
Mailing Address - Street 1:1988 TICE VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94595-2203
Mailing Address - Country:US
Mailing Address - Phone:925-935-6650
Mailing Address - Fax:925-935-6686
Practice Address - Street 1:1988 TICE VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94595-2203
Practice Address - Country:US
Practice Address - Phone:925-935-6650
Practice Address - Fax:925-935-6686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0750640002Medicare NSC