Healthcare Provider Details

I. General information

NPI: 1740868603
Provider Name (Legal Business Name): KENNY HOANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 04/29/2023
Certification Date: 12/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9710 WINTER GARDENS BLVD STE A
LAKESIDE CA
92040-3866
US

IV. Provider business mailing address

9710 WINTER GARDENS BLVD STE A
LAKESIDE CA
92040-3866
US

V. Phone/Fax

Practice location:
  • Phone: 858-357-1463
  • Fax:
Mailing address:
  • Phone: 619-443-1075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number35207TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: