Healthcare Provider Details

I. General information

NPI: 1952604357
Provider Name (Legal Business Name): VIVIAN YEN ILES O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VIVIAN YEN DIEP

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 02/11/2022
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 NORTHGATE DR
MANTECA CA
95336-3139
US

IV. Provider business mailing address

737 W CHILDS AVE
MERCED CA
95341-6805
US

V. Phone/Fax

Practice location:
  • Phone: 866-682-4842
  • Fax: 209-239-5295
Mailing address:
  • Phone: 209-384-6493
  • Fax: 209-359-2045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0003002
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT15424-TLG
License Number StateCA
# 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 Number15424
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: