Healthcare Provider Details

I. General information

NPI: 1851495550
Provider Name (Legal Business Name): XU SHAO HUANG O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56970 YUCCA TRL STE 101
YUCCA VALLEY CA
92284-7911
US

IV. Provider business mailing address

56970 YUCCA TRL STE 101
YUCCA VALLEY CA
92284-7911
US

V. Phone/Fax

Practice location:
  • Phone: 760-228-2020
  • Fax: 760-369-2020
Mailing address:
  • Phone: 760-228-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13213 T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: