Healthcare Provider Details

I. General information

NPI: 1932617909
Provider Name (Legal Business Name): MAGDALENA FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11151 REDFERN AVE
INGLEWOOD CA
90304-2504
US

IV. Provider business mailing address

2043 COLLEGE WAY
FOREST GROVE OR
97116-1756
US

V. Phone/Fax

Practice location:
  • Phone: 310-908-2979
  • Fax:
Mailing address:
  • Phone: 503-352-7217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.0004059
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberD6614593
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number002668
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTPOP109
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberNA2885
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11277T
License Number StateTX
# 7
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-OPT-LIC-4589
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: