Healthcare Provider Details

I. General information

NPI: 1902980147
Provider Name (Legal Business Name): JEAN HOANG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEAN KIM OD

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3951 GRAND AVE
CHINO CA
91710-5429
US

IV. Provider business mailing address

30 TALISMAN
IRVINE CA
92620-3843
US

V. Phone/Fax

Practice location:
  • Phone: 909-627-1507
  • Fax: 909-628-6515
Mailing address:
  • Phone: 909-627-1507
  • Fax: 909-628-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number12816T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: