Provider Demographics
NPI:1184992281
Name:WOODBRIDGE OPTOMETRY
Entity type:Organization
Organization Name:WOODBRIDGE OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:LIKENS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:949-857-0676
Mailing Address - Street 1:4040 BARRANCA PARKWAY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-4772
Mailing Address - Country:US
Mailing Address - Phone:949-857-0676
Mailing Address - Fax:949-857-2175
Practice Address - Street 1:4040 BARRANCA PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4766
Practice Address - Country:US
Practice Address - Phone:949-857-0676
Practice Address - Fax:949-857-2175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8038T152W00000X
CA14184T152W00000X
CA8049T152W00000X
CA7839T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ68757YOtherBLUE SHILED PIN