Provider Demographics
NPI:1750416566
Name:SOUTH PASADENA OPTOMETRIC GROUP, INC.
Entity type:Organization
Organization Name:SOUTH PASADENA OPTOMETRIC GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:CHEN
Authorized Official - Last Name:LEE KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-441-5300
Mailing Address - Street 1:729 MISSION ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3072
Mailing Address - Country:US
Mailing Address - Phone:626-441-5300
Mailing Address - Fax:626-441-2880
Practice Address - Street 1:729 MISSION ST STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-3072
Practice Address - Country:US
Practice Address - Phone:626-441-5300
Practice Address - Fax:626-441-2880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY4697Medicare ID - Type Unspecified