Provider Demographics
NPI:1982227823
Name:LA MIRADA OPTOMETRY
Entity type:Organization
Organization Name:LA MIRADA OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEN-BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-625-6433
Mailing Address - Street 1:10562 RITTER ST
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-4944
Mailing Address - Country:US
Mailing Address - Phone:714-625-6433
Mailing Address - Fax:
Practice Address - Street 1:12819 VALLEY VIEW AVE
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1945
Practice Address - Country:US
Practice Address - Phone:562-921-6659
Practice Address - Fax:562-921-6659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA800341287Medicaid