Provider Demographics
NPI:1255396461
Name:JOHN C PACK, O.D. AND BEVERLY BIANES, O.D. INC
Entity type:Organization
Organization Name:JOHN C PACK, O.D. AND BEVERLY BIANES, O.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FORTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-425-7990
Mailing Address - Street 1:374 E H ST
Mailing Address - Street 2:SUITE 1708
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-7484
Mailing Address - Country:US
Mailing Address - Phone:619-425-7990
Mailing Address - Fax:619-425-7992
Practice Address - Street 1:374 E H ST
Practice Address - Street 2:SUITE 1708
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-7484
Practice Address - Country:US
Practice Address - Phone:619-425-7990
Practice Address - Fax:619-425-7992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD005620Medicaid
CA1255396461OtherBLUE CROSS OF CALIFORNIA
CAW22436Medicare PIN
CA1255396461OtherBLUE CROSS OF CALIFORNIA