=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033715990
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IRINA YAKUBIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2020
-----------------------------------------------------
Last Update Date | 04/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 718 MONTANA AVE
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90403-1404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-917-4474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9201 W SUNSET BLVD STE 709
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90069-3708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-275-5533
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 34722
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------