Healthcare Provider Details

I. General information

NPI: 1497878508
Provider Name (Legal Business Name): MELODY F. VEGA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 E IMPERIAL HWY SUITE C
BREA CA
92821-5627
US

IV. Provider business mailing address

605 E IMPERIAL HWY SUITE C
BREA CA
92821-5627
US

V. Phone/Fax

Practice location:
  • Phone: 714-257-1660
  • Fax: 714-257-1662
Mailing address:
  • Phone: 714-257-1660
  • Fax: 714-257-1662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT 12660 TPA
License Number StateCA

VIII. Authorized Official

Name: MS. MELODY F. VEGA
Title or Position: OWNER
Credential:
Phone: 714-257-1660