Healthcare Provider Details

I. General information

NPI: 1154420602
Provider Name (Legal Business Name): GRIFFIN OPTOMETRIC TALEGA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 06/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 AVE PICO SUITE A
SAN CLEMENTE CA
92673-6956
US

IV. Provider business mailing address

1001 AVE PICO SUITE A
SAN CLEMENTE CA
92673-6956
US

V. Phone/Fax

Practice location:
  • Phone: 949-940-0200
  • Fax: 949-940-0201
Mailing address:
  • Phone: 949-940-0200
  • Fax: 949-940-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1154420602
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number1154420602
License Number StateCA

VIII. Authorized Official

Name: DR. PATRICK AUBURN GRIFFIN
Title or Position: OWNER
Credential: OD
Phone: 949-940-0200