Healthcare Provider Details

I. General information

NPI: 1194027748
Provider Name (Legal Business Name): DIAMOND VISION OPTOMETRY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 S LAKE AVE #111
PASADENA CA
91101-3530
US

IV. Provider business mailing address

350 S LAKE AVE #111
PASADENA CA
91101-3530
US

V. Phone/Fax

Practice location:
  • Phone: 626-683-6868
  • Fax:
Mailing address:
  • Phone: 626-683-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13593
License Number StateCA

VIII. Authorized Official

Name: WILBUR WU
Title or Position: PRESIDENT
Credential: OD
Phone: 626-683-6868