Provider Demographics
NPI:1225168719
Name:VISION SAN GABRIEL OPTOMETRY, INC.
Entity Type:Organization
Organization Name:VISION SAN GABRIEL OPTOMETRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:Y
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-288-8097
Mailing Address - Street 1:720 E VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-3547
Mailing Address - Country:US
Mailing Address - Phone:626-288-8097
Mailing Address - Fax:626-288-8360
Practice Address - Street 1:720 E VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-3547
Practice Address - Country:US
Practice Address - Phone:626-288-8097
Practice Address - Fax:626-288-8360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11494T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0114940Medicaid
CASD0114940Medicaid