Provider Demographics
NPI:1659575736
Name:OPTIQUE OPTOMETRY, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:OPTIQUE OPTOMETRY, A PROFESSIONAL CORPORATION
Other - Org Name:OPTIQUE OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:951-277-2774
Mailing Address - Street 1:2790 CABOT DRIVE
Mailing Address - Street 2:SUITE 135
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883
Mailing Address - Country:US
Mailing Address - Phone:951-277-2774
Mailing Address - Fax:
Practice Address - Street 1:2790 CABOT DRIVE
Practice Address - Street 2:SUITE 135
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92883
Practice Address - Country:US
Practice Address - Phone:951-277-2774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12516152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12516OtherCA OPTOMETRY LICENSE