Provider Demographics
NPI:1407015803
Name:STEPHEN CHINN
Entity Type:Organization
Organization Name:STEPHEN CHINN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-695-7276
Mailing Address - Street 1:45233 ANTARES DR BLDG 2660
Mailing Address - Street 2:P.O.BOX 452134
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92145-4426
Mailing Address - Country:US
Mailing Address - Phone:858-695-7276
Mailing Address - Fax:858-695-7378
Practice Address - Street 1:45233 ANTARES DR BLDG 2660
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92145-4426
Practice Address - Country:US
Practice Address - Phone:858-695-7276
Practice Address - Fax:858-695-7378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5373152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0053731Medicaid
CASD0053731Medicaid
CASD5373BMedicare UPIN
CASD5373BMedicare PIN