=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467764662
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECTRUM VISION OPTOMETRY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2010
-----------------------------------------------------
Last Update Date | 07/06/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6731 WESTMINSTER BLVD 102
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92683-3794
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-379-5495
-----------------------------------------------------
Fax | 714-379-5497
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6731 WESTMINSTER BLVD 102
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92683-3794
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-379-5495
-----------------------------------------------------
Fax | 714-379-5497
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SARAH CHUNG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-701-0425
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 13845
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------