Provider Demographics
NPI:1265895221
Name:MIRA MESA OPTOMETRY, INC
Entity type:Organization
Organization Name:MIRA MESA OPTOMETRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ORLANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:GUIANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-566-6670
Mailing Address - Street 1:8230 MIRA MESA BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-2625
Mailing Address - Country:US
Mailing Address - Phone:858-566-6670
Mailing Address - Fax:858-566-5152
Practice Address - Street 1:8230 MIRA MESA BLVD STE B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-2625
Practice Address - Country:US
Practice Address - Phone:858-566-6670
Practice Address - Fax:858-566-5152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9901152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU376666Medicare UPIN