Healthcare Provider Details

I. General information

NPI: 1942881180
Provider Name (Legal Business Name): MINA CHEN OD CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 PETALUMA BLVD N
PETALUMA CA
94952-2904
US

IV. Provider business mailing address

561 CARLSON AVE APT 332
ROHNERT PARK CA
94928-2801
US

V. Phone/Fax

Practice location:
  • Phone: 707-285-7475
  • Fax: 707-285-7476
Mailing address:
  • Phone: 510-709-7294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. MINA CHEN
Title or Position: OPTOMETRIST, OWNER
Credential: OD
Phone: 510-709-7294