=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396439162
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARNICA OPTOMETRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2023
-----------------------------------------------------
Last Update Date | 06/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1120 S MOUNT VERNON AVE
-----------------------------------------------------
City | COLTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92324-4220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-783-4850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12767 BRIDGEWATER DR
-----------------------------------------------------
City | EASTVALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92880-8848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LAURA L GARNICA
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 909-803-4004
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------