Provider Demographics
NPI:1417224304
Name:GLENDALE OPTOMETRY
Entity Type:Organization
Organization Name:GLENDALE OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:H
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:818-937-9102
Mailing Address - Street 1:232 S BRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-1310
Mailing Address - Country:US
Mailing Address - Phone:818-937-9102
Mailing Address - Fax:
Practice Address - Street 1:232 S BRAND BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1310
Practice Address - Country:US
Practice Address - Phone:818-937-9102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12850T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV06836Medicare UPIN