Provider Demographics
NPI:1245793819
Name:LIM, CHRISTINA (OD)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:LIM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E 8TH ST APT 117
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-2579
Mailing Address - Country:US
Mailing Address - Phone:858-357-5161
Mailing Address - Fax:
Practice Address - Street 1:9170 HAVEN AVE STE 102
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5416
Practice Address - Country:US
Practice Address - Phone:909-440-1014
Practice Address - Fax:909-440-1015
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA34426152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program