Provider Demographics
NPI:1144369372
Name:MARY MCMAINS OD MED AN OPTOMETRIC CORPORATION
Entity type:Organization
Organization Name:MARY MCMAINS OD MED AN OPTOMETRIC CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMAINS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:619-229-9767
Mailing Address - Street 1:3355 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-5703
Mailing Address - Country:US
Mailing Address - Phone:619-229-9767
Mailing Address - Fax:619-692-0747
Practice Address - Street 1:3355 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5703
Practice Address - Country:US
Practice Address - Phone:619-229-9767
Practice Address - Fax:619-692-0747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11525T152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
Not Answered152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Not Answered152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACOR 978OtherCORPORATE LICENSE NUMBER