Healthcare Provider Details

I. General information

NPI: 1588977938
Provider Name (Legal Business Name): TARA VACHARKULKSEMSUK O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 11/30/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32245 MISSION TRL STE D4
LAKE ELSINORE CA
92530-4528
US

IV. Provider business mailing address

32245 MISSION TRL STE D4
LAKE ELSINORE CA
92530-4528
US

V. Phone/Fax

Practice location:
  • Phone: 951-674-1561
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13949
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: