Healthcare Provider Details

I. General information

NPI: 1811680655
Provider Name (Legal Business Name): AGATHA SLEBODA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2619 E COLORADO BLVD # 150
PASADENA CA
91107-3747
US

IV. Provider business mailing address

14726 RAMONA AVE STE 203
CHINO CA
91710-5730
US

V. Phone/Fax

Practice location:
  • Phone: 626-793-4168
  • Fax:
Mailing address:
  • Phone: 626-305-9100
  • Fax: 626-305-0152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number35564
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: