Healthcare Provider Details

I. General information

NPI: 1619464799
Provider Name (Legal Business Name): MICHAEL JOSHUA LIM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2018
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8112 MILLIKEN AVE STE 203
RANCHO CUCAMONGA CA
91730-7473
US

IV. Provider business mailing address

555 N 13TH AVE
UPLAND CA
91786-4904
US

V. Phone/Fax

Practice location:
  • Phone: 909-945-3563
  • Fax: 909-945-9450
Mailing address:
  • Phone: 909-982-8846
  • Fax: 909-206-1097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT34161-TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: