Healthcare Provider Details

I. General information

NPI: 1215384532
Provider Name (Legal Business Name): JENNIFER HUA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 10/15/2024
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 BROCKTON AVE STE 100
RIVERSIDE CA
92506-0107
US

IV. Provider business mailing address

4605 BROCKTON AVE STE 100
RIVERSIDE CA
92506-0107
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-4911
  • Fax: 951-686-9409
Mailing address:
  • Phone: 951-686-4911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT33394-TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: