Provider Demographics
NPI:1578181491
Name:KOSTURA OPTOMETRIC CORP
Entity Type:Organization
Organization Name:KOSTURA OPTOMETRIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:KOSTURA
Authorized Official - Suffix:II
Authorized Official - Credentials:OD
Authorized Official - Phone:949-202-9935
Mailing Address - Street 1:21612 PLANO TRABUCO RD STE C
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-3488
Mailing Address - Country:US
Mailing Address - Phone:949-459-5687
Mailing Address - Fax:949-459-5690
Practice Address - Street 1:21612 PLANO TRABUCO RD STE C
Practice Address - Street 2:
Practice Address - City:TRABUCO CANYON
Practice Address - State:CA
Practice Address - Zip Code:92679-3488
Practice Address - Country:US
Practice Address - Phone:949-459-5687
Practice Address - Fax:949-459-5690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-07
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care