Healthcare Provider Details

I. General information

NPI: 1437422185
Provider Name (Legal Business Name): MERCEDEH MOTAMENI, O.D., AN OPTOMETRIC CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 SEPULVEDA BLVD
CULVER CITY CA
90230-4706
US

IV. Provider business mailing address

4125 SEPULVEDA BLVD
CULVER CITY CA
90230-4706
US

V. Phone/Fax

Practice location:
  • Phone: 310-391-6311
  • Fax: 310-390-1874
Mailing address:
  • Phone: 310-391-6311
  • Fax: 310-390-1874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number9453T
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number9453T
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number9453T
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number9453T
License Number StateCA

VIII. Authorized Official

Name: MERCEDEH MOTAMENI
Title or Position: OPTOMETRIST, OWNER
Credential: O.D.
Phone: 310-391-6311