Healthcare Provider Details

I. General information

NPI: 1174927602
Provider Name (Legal Business Name): LAGUNA HILLS REFRACTIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2014
Last Update Date: 10/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24401 CALLE DE LA LOUISA STE 300
LAGUNA HILLS CA
92653-3623
US

IV. Provider business mailing address

16305 SWINGLEY RIDGE RD 300
CHESTERFIELD MO
63017-1777
US

V. Phone/Fax

Practice location:
  • Phone: 636-534-2300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHARICE Y ANDERSON
Title or Position: GENERAL COUNSEL
Credential:
Phone: 636-534-2234