Healthcare Provider Details

I. General information

NPI: 1568451631
Provider Name (Legal Business Name): JAIME RONELLE KIMIYO OKAMURA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 MDS LOS ANGELES AIR FORCE BASE 483 N AVIATION BLVD
EL SEGUNDO CA
90245
US

IV. Provider business mailing address

61 MDS LOS ANGELES AIR FORCE BASE 483 N AVIATION BLVD
EL SEGUNDO CA
90245
US

V. Phone/Fax

Practice location:
  • Phone: 310-653-6529
  • Fax:
Mailing address:
  • Phone: 310-653-6529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT 12636 T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: