Provider Demographics
NPI:1639392590
Name:EYESMILE OPTOMETRY, INC
Entity Type:Organization
Organization Name:EYESMILE OPTOMETRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MYHANH
Authorized Official - Middle Name:T
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-518-7016
Mailing Address - Street 1:1752 E CARSON ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-2506
Mailing Address - Country:US
Mailing Address - Phone:310-518-7016
Mailing Address - Fax:310-518-7058
Practice Address - Street 1:1752 E CARSON ST
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-2506
Practice Address - Country:US
Practice Address - Phone:310-518-7016
Practice Address - Fax:310-518-7058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12011T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0120110Medicaid
CAOP12011Medicare ID - Type UnspecifiedPROVIDER NUMBER
CAEG290AMedicare PIN
CAU76214Medicare UPIN