Healthcare Provider Details

I. General information

NPI: 1790312064
Provider Name (Legal Business Name): LAUREN LEIKO OGATA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10771 LOS ALAMITOS BLVD
LOS ALAMITOS CA
90720-2309
US

IV. Provider business mailing address

10771 LOS ALAMITOS BLVD
LOS ALAMITOS CA
90720-2309
US

V. Phone/Fax

Practice location:
  • Phone: 562-795-6111
  • Fax:
Mailing address:
  • Phone: 562-795-6111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number61075768
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4522AT
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34779
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: