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General NPI Number Information
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NPI Number | 1164075198
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Entity Type | Individual
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Provider Name | DONG EOK SHIN
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Gender | Male
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Dates
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Enumeration Date | 07/18/2019
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Last Update Date | 01/23/2023
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Provider Practice Location Address
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Address Line | 4250 VAN BUREN BLVD
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City | RIVERSIDE
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State | CA
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Zip | 92503-2602
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Country | US
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Telephone | 909-964-9524
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Fax |
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Provider Business Mailing Address
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Address Line | 23684 GOLD NUGGET AVE
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City | DIAMOND BAR
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State | CA
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Zip | 91765-2335
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Country | US
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Telephone | 213-500-8292
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 70820
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License Number State | CA
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