Healthcare Provider Details

I. General information

NPI: 1508227406
Provider Name (Legal Business Name): ANN VI NGUYEN, OD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2016
Last Update Date: 03/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 EL CAMINO REAL
TUSTIN CA
92782-8918
US

IV. Provider business mailing address

339 GULF STREAM WAY
COSTA MESA CA
92627-2291
US

V. Phone/Fax

Practice location:
  • Phone: 714-592-3222
  • Fax:
Mailing address:
  • Phone: 714-305-0063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number12227
License Number StateCA

VIII. Authorized Official

Name: DR. ANN VI NGUYEN
Title or Position: PRESIDENT
Credential: OD
Phone: 714-305-0063