Healthcare Provider Details

I. General information

NPI: 1437577749
Provider Name (Legal Business Name): BEBAWY OPTOMETRY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 04/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 AUTO CENTER DR
CLAREMONT CA
91711-5458
US

IV. Provider business mailing address

418 AUTO CENTER DR
CLAREMONT CA
91711-5458
US

V. Phone/Fax

Practice location:
  • Phone: 909-621-5400
  • Fax: 909-621-5411
Mailing address:
  • Phone: 909-621-5400
  • Fax: 909-621-5411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number14579TPA
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number14579TPA
License Number StateCA

VIII. Authorized Official

Name: MAGDY AZIZ KEROLLOS BEBAWY
Title or Position: PRESIDENT
Credential: O.D
Phone: 909-235-1998