=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225560725
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRILOGY EYE MEDICAL GROUP, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2017
-----------------------------------------------------
Last Update Date | 04/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 435 ARDEN AVE 430
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91203-1130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-539-8016
-----------------------------------------------------
Fax | 818-351-3657
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 E CALIFORNIA BLVD
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91105-3205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-269-5357
-----------------------------------------------------
Fax | 626-574-7188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | TOM S CHANG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 626-568-8838
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------