Provider Demographics
NPI:1689232795
Name:SHADOWRIDGE FAMILY VISION CENTER OF OPTOMETRY, INC
Entity type:Organization
Organization Name:SHADOWRIDGE FAMILY VISION CENTER OF OPTOMETRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-727-1844
Mailing Address - Street 1:741 SHADOWRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-7997
Mailing Address - Country:US
Mailing Address - Phone:760-727-1844
Mailing Address - Fax:760-727-3044
Practice Address - Street 1:741 SHADOWRIDGE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-7997
Practice Address - Country:US
Practice Address - Phone:760-727-1844
Practice Address - Fax:760-727-3044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty