Healthcare Provider Details

I. General information

NPI: 1750802195
Provider Name (Legal Business Name): SUL KI HAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7339 EL CAJON BLVD STE JK
LA MESA CA
91942-7435
US

IV. Provider business mailing address

426 AUGUSTA LN
PLACENTIA CA
92870-5253
US

V. Phone/Fax

Practice location:
  • Phone: 619-722-8460
  • Fax: 619-722-8465
Mailing address:
  • Phone: 559-261-5063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number9274T
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number9274T
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34171TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: