Provider Demographics
NPI:1154589331
Name:EDEN PLAZA OPTOMETRY
Entity type:Organization
Organization Name:EDEN PLAZA OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOA PHUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:619-758-0639
Mailing Address - Street 1:3555 ROSECRANS ST STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3232
Mailing Address - Country:US
Mailing Address - Phone:619-758-0639
Mailing Address - Fax:619-758-0700
Practice Address - Street 1:3555 ROSECRANS ST STE 102
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3232
Practice Address - Country:US
Practice Address - Phone:619-758-0639
Practice Address - Fax:619-758-0700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-24
Last Update Date:2008-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 12630T152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty