Provider Demographics
NPI:1144313412
Name:JOHN CELIS, O.D., A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JOHN CELIS, O.D., A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DEGUZMAN
Authorized Official - Last Name:CELIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:949-206-1560
Mailing Address - Street 1:23600 ROCKFIELD BLVD
Mailing Address - Street 2:SUITE 3F
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1624
Mailing Address - Country:US
Mailing Address - Phone:949-206-1560
Mailing Address - Fax:949-206-1655
Practice Address - Street 1:23600 ROCKFIELD BLVD
Practice Address - Street 2:SUITE 3F
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1624
Practice Address - Country:US
Practice Address - Phone:949-206-1560
Practice Address - Fax:949-206-1655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-01
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11704T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2462134Medicaid
U88770Medicare UPIN