Provider Demographics
NPI:1144329640
Name:SHLYAKHOV SMILEY OPTOMETRISTS, INC.
Entity type:Organization
Organization Name:SHLYAKHOV SMILEY OPTOMETRISTS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:SMILEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:916-921-8080
Mailing Address - Street 1:701 HOWE AVE STE G48
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-4604
Mailing Address - Country:US
Mailing Address - Phone:916-921-8080
Mailing Address - Fax:
Practice Address - Street 1:701 HOWE AVE STE G48
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-4604
Practice Address - Country:US
Practice Address - Phone:916-921-8080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7061T332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD000820Medicaid
CA4449740001Medicare NSC
CABZ703AMedicare PIN