Healthcare Provider Details

I. General information

NPI: 1154587210
Provider Name (Legal Business Name): TIM C LIU O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2008
Last Update Date: 03/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1552 FOOTHILL BLVD
LA VERNE CA
91750-3434
US

IV. Provider business mailing address

1552 FOOTHILL BLVD
LA VERNE CA
91750
US

V. Phone/Fax

Practice location:
  • Phone: 909-593-4423
  • Fax: 909-593-0176
Mailing address:
  • Phone: 909-593-4423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13573T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: