Provider Demographics
NPI:1598923823
Name:PACIFIC OPTOMETRY VISION, INC.
Entity Type:Organization
Organization Name:PACIFIC OPTOMETRY VISION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHONG
Authorized Official - Middle Name:QUOC
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-810-4535
Mailing Address - Street 1:2402 S AZUSA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-1512
Mailing Address - Country:US
Mailing Address - Phone:626-810-4535
Mailing Address - Fax:626-810-7371
Practice Address - Street 1:2402 S AZUSA AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-1512
Practice Address - Country:US
Practice Address - Phone:626-810-4535
Practice Address - Fax:626-810-7371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11932T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6268104535OtherVSP
CASD0119320Medicaid
CA6268104535OtherVSP
CABQ762AMedicare PIN