Healthcare Provider Details

I. General information

NPI: 1861189011
Provider Name (Legal Business Name): DR. MIMIA WEN OPTOMETRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2651 IRVINE AVE STE 120
COSTA MESA CA
92627-6620
US

IV. Provider business mailing address

2651 IRVINE AVE STE 120
COSTA MESA CA
92627-6620
US

V. Phone/Fax

Practice location:
  • Phone: 949-439-8471
  • Fax:
Mailing address:
  • Phone: 949-432-7894
  • Fax: 949-432-7880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MIMIA WEN
Title or Position: PRESIDENT/AUTHORIZED OFFICIAL
Credential: OD
Phone: 949-432-7894