Provider Demographics
NPI:1811421985
Name:BERNABE, SOFIA
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:BERNABE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20700 AVALON BLVD STE 343
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-3716
Mailing Address - Country:US
Mailing Address - Phone:310-532-2622
Mailing Address - Fax:
Practice Address - Street 1:20700 AVALON BLVD STE 343
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-3716
Practice Address - Country:US
Practice Address - Phone:310-532-2622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-16
Last Update Date:2017-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33348152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist