Provider Demographics
NPI:1568864080
Name:IMPERIAL BEACH OPTOMETRY
Entity Type:Organization
Organization Name:IMPERIAL BEACH OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:GUILY
Authorized Official - Middle Name:
Authorized Official - Last Name:HANONO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-424-9333
Mailing Address - Street 1:10663 AMBERGLADES LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-4841
Mailing Address - Country:US
Mailing Address - Phone:619-424-9333
Mailing Address - Fax:619-424-3356
Practice Address - Street 1:894 PALM AVE
Practice Address - Street 2:STE B
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-1572
Practice Address - Country:US
Practice Address - Phone:619-424-9333
Practice Address - Fax:619-424-3356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2022-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6681TPG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty