Provider Demographics
NPI:1467899880
Name:ICON OPTICAL INC
Entity Type:Organization
Organization Name:ICON OPTICAL INC
Other - Org Name:1001 OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BYUNGSOO
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-385-3388
Mailing Address - Street 1:2880 W OLYMPIC BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2644
Mailing Address - Country:US
Mailing Address - Phone:213-385-3388
Mailing Address - Fax:213-385-3328
Practice Address - Street 1:2880 W OLYMPIC BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2644
Practice Address - Country:US
Practice Address - Phone:213-385-3388
Practice Address - Fax:213-385-3328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27748407261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center