Healthcare Provider Details

I. General information

NPI: 1093109738
Provider Name (Legal Business Name): NICOLE ILANAH KOHAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

695 W FOOTHILL BLVD
CLAREMONT CA
91711-3490
US

IV. Provider business mailing address

9798 FOOTHILL BLVD STE B
RANCHO CUCAMONGA CA
91730-3692
US

V. Phone/Fax

Practice location:
  • Phone: 99-625-7861
  • Fax:
Mailing address:
  • Phone: 714-328-4159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number15243TLG
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number15243TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: