Healthcare Provider Details

I. General information

NPI: 1770898496
Provider Name (Legal Business Name): MARIETTE DEMIANA RIAD O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 08/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 CHANTILLY CIR
SIMI VALLEY CA
93065-7383
US

IV. Provider business mailing address

800 S BREA BLVD #708
BREA CA
92821-5368
US

V. Phone/Fax

Practice location:
  • Phone: 805-279-9884
  • Fax:
Mailing address:
  • Phone: 805-279-9884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13822TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: