Provider Demographics
NPI:1811666506
Name:GLENDORA OPTOMETRY APC
Entity type:Organization
Organization Name:GLENDORA OPTOMETRY APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:CECILIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-914-4815
Mailing Address - Street 1:852 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-4806
Mailing Address - Country:US
Mailing Address - Phone:626-914-4815
Mailing Address - Fax:626-914-0502
Practice Address - Street 1:852 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-4806
Practice Address - Country:US
Practice Address - Phone:626-914-4815
Practice Address - Fax:626-914-0502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0107920Medicaid