Healthcare Provider Details

I. General information

NPI: 1639162076
Provider Name (Legal Business Name): FANNY LEE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 W WEST COVINA PKWY STE B
WEST COVINA CA
91790-8212
US

IV. Provider business mailing address

1026 W WEST COVINA PKWY STE B
WEST COVINA CA
91790-8212
US

V. Phone/Fax

Practice location:
  • Phone: 626-962-5868
  • Fax:
Mailing address:
  • Phone: 626-962-5868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11688
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: