Healthcare Provider Details

I. General information

NPI: 1639688179
Provider Name (Legal Business Name): RENIA MALEK OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 01/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E CALIFORNIA BLVD
PASADENA CA
91105-3205
US

IV. Provider business mailing address

100 E CALIFORNIA BLVD
PASADENA CA
91105-3205
US

V. Phone/Fax

Practice location:
  • Phone: 626-568-8838
  • Fax: 626-583-8838
Mailing address:
  • Phone: 626-568-8838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number33840TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: