Healthcare Provider Details

I. General information

NPI: 1245357565
Provider Name (Legal Business Name): LYNN EYE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 LYNN RD STE 102
THOUSAND OAKS CA
91360-1920
US

IV. Provider business mailing address

2230 LYNN RD STE 102
THOUSAND OAKS CA
91360-1920
US

V. Phone/Fax

Practice location:
  • Phone: 805-495-0458
  • Fax: 805-494-9630
Mailing address:
  • Phone: 805-495-0458
  • Fax: 805-494-9630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1100X
TaxonomyOphthalmic Technician/Technologist
License NumberG44847
License Number StateCA

VIII. Authorized Official

Name: CHARLES ALAN COOPER
Title or Position: OPHTHALMOLOGIST
Credential: M.D.
Phone: 805-495-0458