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NPI Code Detail

MEDICARE: COLLEGE GROVE OPTOMETRY

MEDICARE: COLLEGE GROVE OPTOMETRY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1255658456
Entity Type Code : Organization
Provider Name (Legal Business Name) : COLLEGE GROVE OPTOMETRY
Provider Business Mailing Address
First Line : 3408 COLLEGE AVE
Second Line :
City : SAN DIEGO
State : CA
Zip : 92115-7134
Country : US
Telephone Number : 619-957-0443
Fax Number :
Provider Business Practice Location Address
First Line : 3408 COLLEGE AVE
Second Line :
City : SAN DIEGO
State : CA
Zip : 92115-7134
Country : US
Telephone Number : 619-957-0443
Fax Number :
Authorized Official
Title or Position : CEO
Name : DR. HOA PHUONG NGUYEN
Credential : O.D.
Telephone Number : 619-957-0443
Provider Enumeration Date : 04/27/2010
Last Update Date : 09/15/2010

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1942467238 — COLLEGE GROVE OPTOMETRY
Practice Location Address:
3408 COLLEGE AVE
SAN DIEGO, CA
92115-7134
Practice Phone: 619-583-5744
Practice Fax: 619-583-5744

Directions to “COLLEGE GROVE OPTOMETRY ” Practice Location

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