Provider Demographics
NPI:1437145372
Name:COMMERCE CENTER OPTOMETRY INC.
Entity Type:Organization
Organization Name:COMMERCE CENTER OPTOMETRY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAUNETTE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:323-728-2708
Mailing Address - Street 1:5520 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-4104
Mailing Address - Country:US
Mailing Address - Phone:323-728-2708
Mailing Address - Fax:323-728-0096
Practice Address - Street 1:5520 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-4104
Practice Address - Country:US
Practice Address - Phone:323-728-2708
Practice Address - Fax:323-728-0096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACOR 948152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD004440Medicaid
CAGSD004440Medicaid