Healthcare Provider Details

I. General information

NPI: 1598805269
Provider Name (Legal Business Name): LEYBIN LAKESIDE OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2645 OCEAN AVE SUITE #2
SAN FRANCISCO CA
94132-1633
US

IV. Provider business mailing address

2645 OCEAN AVE SUITE #2
SAN FRANCISCO CA
94132-1633
US

V. Phone/Fax

Practice location:
  • Phone: 415-334-2022
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberSL799
License Number StateCA

VIII. Authorized Official

Name: MR. LEONID LEONARD LEYBIN
Title or Position: OWNER
Credential: OPTICIAN
Phone: 415-334-2022