Provider Demographics
NPI:1790047660
Name:JIMMY K SO OD INC
Entity Type:Organization
Organization Name:JIMMY K SO OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:K
Authorized Official - Last Name:SO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-982-9366
Mailing Address - Street 1:1261 W FOOTHILL BLVD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-8018
Mailing Address - Country:US
Mailing Address - Phone:909-982-9366
Mailing Address - Fax:909-982-2477
Practice Address - Street 1:1261 W FOOTHILL BLVD
Practice Address - Street 2:SUITE 8
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-8018
Practice Address - Country:US
Practice Address - Phone:909-982-9366
Practice Address - Fax:909-982-2477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty