Provider Demographics
NPI:1780124792
Name:LARRY ALENBAUGH OPTOMETRY
Entity type:Organization
Organization Name:LARRY ALENBAUGH OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALENBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-246-2096
Mailing Address - Street 1:1807 N SHATTUCK PL
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92865-4640
Mailing Address - Country:US
Mailing Address - Phone:626-246-2096
Mailing Address - Fax:
Practice Address - Street 1:NAS NORTH ISLAND BUILDING 2017
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92135
Practice Address - Country:US
Practice Address - Phone:619-435-1308
Practice Address - Fax:619-435-1308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12542TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABA294Medicare PIN