Healthcare Provider Details

I. General information

NPI: 1346079472
Provider Name (Legal Business Name): JENILEE LIANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11540 SANTA MONICA BLVD STE 202
LOS ANGELES CA
90025-7905
US

IV. Provider business mailing address

13089 HILLHAVEN CT
VICTORVILLE CA
92392-0575
US

V. Phone/Fax

Practice location:
  • Phone: 310-473-5464
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number35765
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: