Healthcare Provider Details

I. General information

NPI: 1982254785
Provider Name (Legal Business Name): TRISTINA CHUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2019
Last Update Date: 12/17/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 E FOOTHILL BLVD STE 207
PASADENA CA
91107-7111
US

IV. Provider business mailing address

78 E BAY STATE ST UNIT 3A
ALHAMBRA CA
91801-6819
US

V. Phone/Fax

Practice location:
  • Phone: 626-578-9685
  • Fax:
Mailing address:
  • Phone: 909-677-8655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number34352TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: