Healthcare Provider Details

I. General information

NPI: 1750572244
Provider Name (Legal Business Name): V. T. LY OD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 08/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16341 HARBOR BLVD
FOUNTAIN VALLEY CA
92708-1311
US

IV. Provider business mailing address

16341 HARBOR BLVD
FOUNTAIN VALLEY CA
92708-1311
US

V. Phone/Fax

Practice location:
  • Phone: 714-839-2021
  • Fax: 714-839-3918
Mailing address:
  • Phone: 714-839-2021
  • Fax: 714-839-3918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10370T
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number10370T
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number10370T
License Number StateCA

VIII. Authorized Official

Name: DR. VAN T. LY
Title or Position: OPTOMETRIST
Credential: OD
Phone: 714-839-2021