Healthcare Provider Details

I. General information

NPI: 1861788218
Provider Name (Legal Business Name): BOOTH OPTOMETRY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 09/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 IRVINE BLVD
TUSTIN CA
92780-3529
US

IV. Provider business mailing address

1102 IRVINE BLVD
TUSTIN CA
92780-3529
US

V. Phone/Fax

Practice location:
  • Phone: 714-838-3210
  • Fax: 714-838-5702
Mailing address:
  • Phone: 714-838-3210
  • Fax: 714-838-5702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-11505-TPA
License Number StateCA

VIII. Authorized Official

Name: AMY LOUISE KAYEKJIAN
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 714-838-3210