Provider Demographics
NPI:1184900037
Name:KOBAYASHI OPTOMETRIC INC
Entity type:Organization
Organization Name:KOBAYASHI OPTOMETRIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOBAYASHI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-823-4595
Mailing Address - Street 1:13161 MINDANAO WAY # D6A
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6307
Mailing Address - Country:US
Mailing Address - Phone:310-823-4595
Mailing Address - Fax:
Practice Address - Street 1:13161 MINDANAO WAY # D6A
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6307
Practice Address - Country:US
Practice Address - Phone:310-823-4595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-24
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9444T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0094440Medicaid
CASD0094440Medicaid
CAFT273AMedicare PIN