Healthcare Provider Details

I. General information

NPI: 1508143827
Provider Name (Legal Business Name): IMPERIAL VALLEY OPTOMTRIC CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2011
Last Update Date: 11/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 IMPERIAL AVE. W. STE 103
CALEXICO CA
92231
US

IV. Provider business mailing address

3451 S DOGWOOD AVE STE 1334
EL CENTRO CA
92243
US

V. Phone/Fax

Practice location:
  • Phone: 760-336-3003
  • Fax: 888-210-5799
Mailing address:
  • Phone: 760-768-9484
  • Fax: 888-210-5799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MAY C TAM
Title or Position: VICE PRESIDENT
Credential: O.D.
Phone: 760-336-3003