Healthcare Provider Details

I. General information

NPI: 1225686215
Provider Name (Legal Business Name): JACQUELINE MING LEW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2056 WESTMINSTER MALL
WESTMINSTER CA
92683-4947
US

IV. Provider business mailing address

3 GLENHAVEN LN
IRVINE CA
92620-1206
US

V. Phone/Fax

Practice location:
  • Phone: 714-897-0996
  • Fax:
Mailing address:
  • Phone: 949-214-6736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34350TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: