Healthcare Provider Details

I. General information

NPI: 1043640675
Provider Name (Legal Business Name): CUPERTINO VILLAGE OPTOMETRY, APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2013
Last Update Date: 11/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10969 N WOLFE RD
CUPERTINO CA
95014-0617
US

IV. Provider business mailing address

10969 N WOLFE RD
CUPERTINO CA
95014-0617
US

V. Phone/Fax

Practice location:
  • Phone: 408-873-1718
  • Fax: 408-873-1026
Mailing address:
  • Phone: 408-873-1718
  • Fax: 408-873-1026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number12434TPL
License Number StateCA

VIII. Authorized Official

Name: KAI SHUM
Title or Position: CFO
Credential:
Phone: 408-873-1718