=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174189716
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIMIA WEN OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2019
-----------------------------------------------------
Last Update Date | 07/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2651 IRVINE AVE STE 120
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92627-6620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-432-7894
-----------------------------------------------------
Fax | 949-432-7880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4505 BARRANCA PKWY STE C
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92604-4797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-857-0676
-----------------------------------------------------
Fax | 949-857-2175
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT34428TLG
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------