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General NPI Number Information
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NPI Number | 1023981859
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Entity Type | Organization
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Legal Business Name | PENINSULA PROFESSIONAL SERVICES
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Dates
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Enumeration Date | 09/26/2025
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Last Update Date | 09/26/2025
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Provider Practice Location Address
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Address Line | 21200 BEACH BLVD
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City | HUNTINGTON BEACH
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State | CA
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Zip | 92648-5411
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Country | US
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Telephone | 714-374-2626
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Fax |
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Provider Business Mailing Address
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Address Line | 21200 BEACH BLVD
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City | HUNTINGTON BEACH
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State | CA
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Zip | 92648-5411
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Country | US
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Telephone | 714-374-2626
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | JACK IBRAHIM
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Credential | OD
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Telephone | 909-919-6044
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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