Healthcare Provider Details

I. General information

NPI: 1871546341
Provider Name (Legal Business Name): AGOURA-WEST VALLEY OPTOMETRIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 OWENSMOUTH AVE #400
CANOGA PARK CA
91303-3159
US

IV. Provider business mailing address

6800 OWENSMOUTH AVE #400
CANOGA PARK CA
91303-3159
US

V. Phone/Fax

Practice location:
  • Phone: 818-340-5796
  • Fax: 818-340-4030
Mailing address:
  • Phone: 818-340-5796
  • Fax: 818-340-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8019TPL
License Number StateCA

VIII. Authorized Official

Name: DR. DANITA SAM LAI
Title or Position: PRESIDENT
Credential: O.D.
Phone: 818-340-5796