Healthcare Provider Details

I. General information

NPI: 1932938883
Provider Name (Legal Business Name): JENNIFER GRACE LE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 ROYALTY DR STE 100
POMONA CA
91767-3048
US

IV. Provider business mailing address

15273 MAYSAIR LN
CHINO HILLS CA
91709-4285
US

V. Phone/Fax

Practice location:
  • Phone: 909-469-4804
  • Fax: 909-469-4807
Mailing address:
  • Phone: 909-544-9091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT36073-TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: