Provider Demographics
NPI:1932482551
Name:VISION EXPRESS OPTOMETRY
Entity Type:Organization
Organization Name:VISION EXPRESS OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-949-6363
Mailing Address - Street 1:16803 VALLEY BLVD
Mailing Address - Street 2:UNIT A
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-9242
Mailing Address - Country:US
Mailing Address - Phone:909-349-0299
Mailing Address - Fax:909-474-7740
Practice Address - Street 1:16803 VALLEY BLVD
Practice Address - Street 2:UNIT A
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-9242
Practice Address - Country:US
Practice Address - Phone:909-349-0299
Practice Address - Fax:909-474-7740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12779T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty