Healthcare Provider Details

I. General information

NPI: 1649823618
Provider Name (Legal Business Name): SAND PACIFIC EYE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1964 WESTWOOD BLVD STE 125
LOS ANGELES CA
90025-8405
US

IV. Provider business mailing address

1964 WESTWOOD BLVD STE 125
LOS ANGELES CA
90025-8405
US

V. Phone/Fax

Practice location:
  • Phone: 310-441-2263
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL SAND
Title or Position: AGENT OF SERVICE
Credential: MD
Phone: 310-750-3820