Healthcare Provider Details

I. General information

NPI: 1104261957
Provider Name (Legal Business Name): MNT OPTOMETRIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2013
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2049 BREA MALL
BREA CA
92821-5756
US

IV. Provider business mailing address

2049 BREA MALL
BREA CA
92821-5756
US

V. Phone/Fax

Practice location:
  • Phone: 714-990-9311
  • Fax: 714-990-2633
Mailing address:
  • Phone: 714-990-9311
  • Fax: 714-990-2633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. CRYSTAL MURAOKA
Title or Position: OPTOMETRIST
Credential: OD
Phone: 714-478-0652