Healthcare Provider Details

I. General information

NPI: 1902383540
Provider Name (Legal Business Name): STEPHANIE LE ASIS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 09/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47-474 WASHINGTON ST.
LA QUINTA CA
92253
US

IV. Provider business mailing address

3265 E MIDSUMMER PRIVADO UNIT 1
ONTARIO CA
91762-7541
US

V. Phone/Fax

Practice location:
  • Phone: 800-898-2020
  • Fax:
Mailing address:
  • Phone: 951-756-1023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34013TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: