Provider Demographics
NPI:1548465222
Name:VISION CARE CENTER OF SOUTHEASTERN CA AN OPTOMETRIC CORP.
Entity type:Organization
Organization Name:VISION CARE CENTER OF SOUTHEASTERN CA AN OPTOMETRIC CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BARNISKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-351-2020
Mailing Address - Street 1:PO BOX 1071
Mailing Address - Street 2:
Mailing Address - City:BRAWLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92227-1071
Mailing Address - Country:US
Mailing Address - Phone:760-351-2020
Mailing Address - Fax:760-344-4552
Practice Address - Street 1:260 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-2351
Practice Address - Country:US
Practice Address - Phone:760-351-2020
Practice Address - Fax:760-344-4552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA005636152WC0802X, 152WL0500X, 152WP0200X, 152WV0400X, 152WX0102X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWY2550OtherMEDICARE PROVIDER
CA1548465222Medicaid
CA1982760310OtherNPI
CAT10062Medicare UPIN