Provider Demographics
NPI:1366579468
Name:PACIFIC EYE CENTER
Entity type:Organization
Organization Name:PACIFIC EYE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:MENDOZA
Authorized Official - Last Name:DIZON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:671-637-9889
Mailing Address - Street 1:562 HARMON LOOP RD
Mailing Address - Street 2:STE D2
Mailing Address - City:DEDEDO
Mailing Address - State:GU
Mailing Address - Zip Code:96929
Mailing Address - Country:US
Mailing Address - Phone:671-637-9889
Mailing Address - Fax:671-632-5558
Practice Address - Street 1:562 HARMON LOOP RD
Practice Address - Street 2:STE D2
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929
Practice Address - Country:US
Practice Address - Phone:671-637-9889
Practice Address - Fax:671-632-5558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUOL026152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GUD3816501Medicaid