Healthcare Provider Details

I. General information

NPI: 1922148634
Provider Name (Legal Business Name): KRISTIE ANH VO O.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 12/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6445 PATS RANCH RD STE D
MIRA LOMA CA
91752-4439
US

IV. Provider business mailing address

6445 PATS RANCH RD STE D
MIRA LOMA CA
91752-4439
US

V. Phone/Fax

Practice location:
  • Phone: 951-371-3937
  • Fax: 951-371-6735
Mailing address:
  • Phone: 951-371-3937
  • Fax: 951-371-6735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11402T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: