Healthcare Provider Details

I. General information

NPI: 1790509644
Provider Name (Legal Business Name): SIMON VINCENZO GUZMAN LDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2024
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 JESSICA WAY
ATHENS GA
30606-1393
US

IV. Provider business mailing address

450 JESSICA WAY
ATHENS GA
30606-1393
US

V. Phone/Fax

Practice location:
  • Phone: 626-226-6992
  • Fax:
Mailing address:
  • Phone: 626-226-6992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FC0800X
TaxonomyContact Lens Technician/Technologist
License NumberLDO003009
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code156FX1100X
TaxonomyOphthalmic Technician/Technologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberLDO003009
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: