Provider Demographics
NPI:1598792889
Name:CERRITOS EYE MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:CERRITOS EYE MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TAE
Authorized Official - Middle Name:SUN
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-402-4720
Mailing Address - Street 1:11829 SOUTH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-6828
Mailing Address - Country:US
Mailing Address - Phone:562-402-4720
Mailing Address - Fax:562-402-9231
Practice Address - Street 1:11829 SOUTH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-6828
Practice Address - Country:US
Practice Address - Phone:562-402-4720
Practice Address - Fax:562-402-9231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG96402207W00000X
CAA87753207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA87753COtherMEDICARE PTAN
CA00A877530Medicaid
CAGR0091370Medicaid
CAWA87753COtherMEDICARE PTAN
CA00A877530Medicaid
CAGR0091370Medicaid
CAW15275AMedicare ID - Type Unspecified