Provider Demographics
NPI:1295831485
Name:KT TONNU AN OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:KT TONNU AN OPTOMETRIC CORPORATION
Other - Org Name:POMONA OPTOMETRY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIEUTIEN
Authorized Official - Middle Name:PHAN
Authorized Official - Last Name:TONNU
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-620-4546
Mailing Address - Street 1:1101 E HOLT AVE
Mailing Address - Street 2:STE D
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5800
Mailing Address - Country:US
Mailing Address - Phone:909-620-4546
Mailing Address - Fax:909-620-4546
Practice Address - Street 1:1101 E HOLT AVE
Practice Address - Street 2:STE D
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5800
Practice Address - Country:US
Practice Address - Phone:909-620-4546
Practice Address - Fax:909-620-4546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10429T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASDO104290Medicaid
CASDO104290Medicaid
CAWOP10429FMedicare PIN
U51704Medicare UPIN