Provider Demographics
NPI:1740216936
Name:GOLDEN SAN GABRIEL OPTOMETRIC VISION CENTER
Entity Type:Organization
Organization Name:GOLDEN SAN GABRIEL OPTOMETRIC VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIS
Authorized Official - Prefix:DR
Authorized Official - First Name:JIYEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-288-8023
Mailing Address - Street 1:140 W VALLEY BLVD
Mailing Address - Street 2:#115
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-3760
Mailing Address - Country:US
Mailing Address - Phone:626-288-8023
Mailing Address - Fax:626-288-8326
Practice Address - Street 1:140 W VALLEY BLVD
Practice Address - Street 2:#115
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-3760
Practice Address - Country:US
Practice Address - Phone:626-288-8023
Practice Address - Fax:626-288-8326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9727152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD001490Medicaid
CAGSD001490Medicaid
CAWY154Medicare PIN