Provider Demographics
NPI:1609033992
Name:STACEY QT LE, OD PROFESSIONAL OPTOMETRY CORPORATION
Entity Type:Organization
Organization Name:STACEY QT LE, OD PROFESSIONAL OPTOMETRY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:QT
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-895-4899
Mailing Address - Street 1:7038 KATELLA AVE
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-2805
Mailing Address - Country:US
Mailing Address - Phone:714-895-4899
Mailing Address - Fax:
Practice Address - Street 1:7038 KATELLA AVE
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-2805
Practice Address - Country:US
Practice Address - Phone:714-895-4899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOP10232261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0102320Medicaid
CASD0102320Medicaid