Healthcare Provider Details

I. General information

NPI: 1457060857
Provider Name (Legal Business Name): HILLSIDE OPTOMETRY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16907 SAN FERNANDO MISSION BLVD
GRANADA HILLS CA
91344-4250
US

IV. Provider business mailing address

16907 SAN FERNANDO MISSION BLVD
GRANADA HILLS CA
91344-4250
US

V. Phone/Fax

Practice location:
  • Phone: 818-474-2020
  • Fax:
Mailing address:
  • Phone: 818-474-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. ANDY KONGSAKUL
Title or Position: PRESIDENT
Credential: OD
Phone: 818-474-2020