Provider Demographics
NPI:1609992940
Name:HA, NICOLE-NINCHO PHU (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE-NINCHO
Middle Name:PHU
Last Name:HA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 BROCKTON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-0106
Mailing Address - Country:US
Mailing Address - Phone:951-686-4911
Mailing Address - Fax:951-686-9409
Practice Address - Street 1:4605 BROCKTON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-0106
Practice Address - Country:US
Practice Address - Phone:951-686-4911
Practice Address - Fax:951-686-9409
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 10694T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0106940Medicaid
CAOPT 10694TOtherSTATE LICENSE
CASD0106940Medicaid