Provider Demographics
NPI:1922253509
Name:VISION EXPRESS OPTOMETRY, INC.
Entity Type:Organization
Organization Name:VISION EXPRESS OPTOMETRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SUNG
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-949-6363
Mailing Address - Street 1:15923 BEAR VALLEY ROAD
Mailing Address - Street 2:SUITE B-100
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-1762
Mailing Address - Country:US
Mailing Address - Phone:760-949-6363
Mailing Address - Fax:760-949-9249
Practice Address - Street 1:15923 BEAR VALLEY RD
Practice Address - Street 2:SUITE B-100
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1750
Practice Address - Country:US
Practice Address - Phone:760-949-6363
Practice Address - Fax:760-949-9249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12779T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1848938Medicaid
CA1848938Medicaid