Provider Demographics
NPI:1023409927
Name:RICHARD VANOVER OPTOMETRY
Entity type:Organization
Organization Name:RICHARD VANOVER OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:VANOVER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-951-0820
Mailing Address - Street 1:3133 W MARCH LN STE 2020
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2361
Mailing Address - Country:US
Mailing Address - Phone:209-951-0820
Mailing Address - Fax:209-951-2348
Practice Address - Street 1:3133 W MARCH LN STE 2020
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-2361
Practice Address - Country:US
Practice Address - Phone:209-951-0820
Practice Address - Fax:209-951-2348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-12
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9667T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA156765Medicare PIN