Healthcare Provider Details

I. General information

NPI: 1962031617
Provider Name (Legal Business Name): TINA KHIEU OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2020
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 GENESEE AVE STE 310
LA JOLLA CA
92037-1208
US

IV. Provider business mailing address

360 SIERRA COLLEGE DR STE 100
GRASS VALLEY CA
95945-5088
US

V. Phone/Fax

Practice location:
  • Phone: 800-898-2020
  • Fax:
Mailing address:
  • Phone: 530-273-3190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34777
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: