Healthcare Provider Details

I. General information

NPI: 1891232096
Provider Name (Legal Business Name): WOODBRIDGE OPTOMETRY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 02/22/2020
Certification Date: 02/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 BARRANCA PKWY SUITE C
IRVINE CA
92604-4707
US

IV. Provider business mailing address

4505 BARRANCA PKWY SUITE C
IRVINE CA
92604-4707
US

V. Phone/Fax

Practice location:
  • Phone: 949-857-0676
  • Fax: 949-857-2175
Mailing address:
  • Phone: 949-857-0676
  • Fax: 949-857-2175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number9377TPL
License Number StateCA

VIII. Authorized Official

Name: DR. ALISSA SUE WALD
Title or Position: OWNER
Credential: OD
Phone: 949-857-0676