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General NPI Number Information
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NPI Number | 1437992864
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Entity Type | Organization
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Legal Business Name | JESSIA T LY OD INC
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Dates
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Enumeration Date | 06/14/2024
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Last Update Date | 06/14/2024
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Provider Practice Location Address
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Address Line | 618 W HUNTINGTON DR
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City | MONROVIA
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State | CA
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Zip | 91016-3206
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Country | US
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Telephone | 626-303-1966
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Fax |
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Provider Business Mailing Address
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Address Line | 411 E DUARTE RD APT 4
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City | ARCADIA
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State | CA
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Zip | 91006-3973
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Country | US
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Telephone | 323-719-1500
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | JESSICA T LY
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Credential | OD
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Telephone | 323-719-1500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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