Healthcare Provider Details

I. General information

NPI: 1356507503
Provider Name (Legal Business Name): EYE STUDIO OPTOMETRY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 07/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4475 UNIVERSITY AVE
SAN DIEGO CA
92105-1731
US

IV. Provider business mailing address

4475 UNIVERSITY AVE
SAN DIEGO CA
92105-1731
US

V. Phone/Fax

Practice location:
  • Phone: 619-618-2954
  • Fax: 619-618-2954
Mailing address:
  • Phone: 619-521-2025
  • Fax: 619-521-2025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number12792
License Number StateCA

VIII. Authorized Official

Name: DR. LESLIE CHEN
Title or Position: PRESIDENT
Credential: O.D.
Phone: 619-521-2020