Provider Demographics
NPI:1548339112
Name:MANTECA OPTOMETRY
Entity type:Organization
Organization Name:MANTECA OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:LEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-239-3504
Mailing Address - Street 1:1532 BENNINGTON CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-4556
Mailing Address - Country:US
Mailing Address - Phone:209-477-3888
Mailing Address - Fax:
Practice Address - Street 1:158 N MAPLE AVE
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4503
Practice Address - Country:US
Practice Address - Phone:209-239-3504
Practice Address - Fax:209-239-0741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12388T152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1982704979OtherMY NPI NUMBER
CAV02468Medicare UPIN
CASD0123880Medicare ID - Type Unspecified