Healthcare Provider Details

I. General information

NPI: 1356837546
Provider Name (Legal Business Name): THAI TRAN OPTOMETRY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 ADAMS AVE STE 102
COSTA MESA CA
92626
US

IV. Provider business mailing address

1500 ADAMS AVE STE 102
COSTA MESA CA
92626-3864
US

V. Phone/Fax

Practice location:
  • Phone: 714-200-3629
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number14289TLG
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number14289TLG
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14289TLG
License Number StateCA

VIII. Authorized Official

Name: DR. THAI TRAN
Title or Position: PRESIDENT
Credential: O.D.
Phone: 714-617-5030