Provider Demographics
NPI:1639745821
Name:PROSPECTIVE VISION OPTOMETRIC CORP
Entity type:Organization
Organization Name:PROSPECTIVE VISION OPTOMETRIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:562-377-0941
Mailing Address - Street 1:7250 CARSON BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-2358
Mailing Address - Country:US
Mailing Address - Phone:562-377-0941
Mailing Address - Fax:562-330-2687
Practice Address - Street 1:7250 CARSON BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-2358
Practice Address - Country:US
Practice Address - Phone:562-377-0941
Practice Address - Fax:562-330-2687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-28
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB319343OtherMEDICARE