Provider Demographics
NPI:1922420108
Name:DR TANYA OPTOMETRY
Entity Type:Organization
Organization Name:DR TANYA OPTOMETRY
Other - Org Name:MINTZ FAMILY OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LETHUY
Authorized Official - Middle Name:THI
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-985-2876
Mailing Address - Street 1:563 N MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5016
Mailing Address - Country:US
Mailing Address - Phone:909-985-2876
Mailing Address - Fax:909-946-8585
Practice Address - Street 1:563 N MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5016
Practice Address - Country:US
Practice Address - Phone:909-985-2876
Practice Address - Fax:909-946-8585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-07
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9953152W00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0099530Medicaid
U37341Medicare UPIN