Healthcare Provider Details

I. General information

NPI: 1225304967
Provider Name (Legal Business Name): WINK OPTOMETRY & EYEWEAR, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2673 VIA DE LA VALLE SUITE E F
DEL MAR CA
92014-1912
US

IV. Provider business mailing address

2673 VIA DE LA VALLE SUITE E F
DEL MAR CA
92014-1912
US

V. Phone/Fax

Practice location:
  • Phone: 858-755-9465
  • Fax: 858-755-9468
Mailing address:
  • Phone: 858-755-9465
  • Fax: 858-755-9468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number11596T
License Number StateCA

VIII. Authorized Official

Name: DR. PUNEH BAHA
Title or Position: OWNER/PRESIDENT
Credential: OD
Phone: 858-755-9465