Provider Demographics
NPI:1275143661
Name:WFT OPTOMETRIC GROUP
Entity Type:Organization
Organization Name:WFT OPTOMETRIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:FONG
Authorized Official - Last Name:TOM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:213-220-9241
Mailing Address - Street 1:2825 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-3603
Mailing Address - Country:US
Mailing Address - Phone:323-373-9633
Mailing Address - Fax:323-373-9844
Practice Address - Street 1:2825 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-3603
Practice Address - Country:US
Practice Address - Phone:323-373-9633
Practice Address - Fax:323-373-9844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-31
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0946900Medicaid