Healthcare Provider Details

I. General information

NPI: 1336787043
Provider Name (Legal Business Name): JIMMY QUANG OD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2019
Last Update Date: 09/07/2024
Certification Date: 09/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31401 RANCHO VIEJO RD STE 103
SAN JUAN CAPISTRANO CA
92675-1850
US

IV. Provider business mailing address

31401 RANCHO VIEJO RD STE 103
SAN JUAN CAPISTRANO CA
92675-1850
US

V. Phone/Fax

Practice location:
  • Phone: 949-443-3794
  • Fax: 949-443-3828
Mailing address:
  • Phone: 510-637-9987
  • Fax: 949-443-3828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: JIMMY QUANG
Title or Position: PRESIDENT
Credential: OD
Phone: 510-637-9987