Healthcare Provider Details

I. General information

NPI: 1306950829
Provider Name (Legal Business Name): GARY L ETTING OD AN OPTOMETRIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6345 BALBOA BLVD BLDG 3 SUITE 250
ENCINO CA
91316
US

IV. Provider business mailing address

6345 BALBOA BLVD BLDG 3 SUITE 250
ENCINO CA
91316
US

V. Phone/Fax

Practice location:
  • Phone: 818-344-3937
  • Fax: 818-344-1229
Mailing address:
  • Phone: 818-344-3937
  • Fax: 818-344-1229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT 5519 T
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT5519
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOPT 5519 T
License Number StateCA

VIII. Authorized Official

Name: DR. GARY L ETTING
Title or Position: OWNER
Credential: OD
Phone: 818-344-3937