Healthcare Provider Details

I. General information

NPI: 1427366145
Provider Name (Legal Business Name): SAN CLEMENTE OPTOMETRY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 04/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 AVENIDA DEL MAR SUITE A
SAN CLEMENTE CA
92672-4011
US

IV. Provider business mailing address

224 AVENIDA DEL MAR SUITE A
SAN CLEMENTE CA
92672-4011
US

V. Phone/Fax

Practice location:
  • Phone: 949-492-2029
  • Fax: 949-492-0049
Mailing address:
  • Phone: 949-492-2029
  • Fax: 949-492-0049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10391T
License Number StateCA

VIII. Authorized Official

Name: DR. DAVID J NOTA
Title or Position: PRESIDENT
Credential: O.D.
Phone: 949-492-2029