Healthcare Provider Details

I. General information

NPI: 1013839612
Provider Name (Legal Business Name): VY VY LU OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11980 MOUNT VERNON AVE
GRAND TERRACE CA
92313-5172
US

IV. Provider business mailing address

1194 W ORANGE GROVE AVE
POMONA CA
91768-2957
US

V. Phone/Fax

Practice location:
  • Phone: 909-864-1097
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT36297-TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: