Provider Demographics
NPI:1811188980
Name:VAN T. LY OD INC.
Entity Type:Organization
Organization Name:VAN T. LY OD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:818-353-7575
Mailing Address - Street 1:8043 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:SUNLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91040-2957
Mailing Address - Country:US
Mailing Address - Phone:818-353-7575
Mailing Address - Fax:818-353-8925
Practice Address - Street 1:8043 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SUNLAND
Practice Address - State:CA
Practice Address - Zip Code:91040-2957
Practice Address - Country:US
Practice Address - Phone:818-353-7575
Practice Address - Fax:818-353-8925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10370T152W00000X, 152WC0802X, 152WL0500X, 152WP0200X
CA10812T152W00000X, 152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty