Healthcare Provider Details

I. General information

NPI: 1508944711
Provider Name (Legal Business Name): JUSTIN T. ABO, O.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12759 FOOTHILL BLVD SUITE D
RANCHO CUCAMONGA CA
91739-9336
US

IV. Provider business mailing address

12759 FOOTHILL BLVD SUITE D
RANCHO CUCAMONGA CA
91739-9336
US

V. Phone/Fax

Practice location:
  • Phone: 909-899-0026
  • Fax: 909-899-6381
Mailing address:
  • Phone: 909-899-0026
  • Fax: 909-899-6381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11100T
License Number StateCA

VIII. Authorized Official

Name: JUSTIN T ABO
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 909-899-0026