=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487703963
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOLD OPTOMETRY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2007
-----------------------------------------------------
Last Update Date | 05/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 833 S WESTERN AVE #2
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90005-3376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-384-1001
-----------------------------------------------------
Fax | 213-384-4527
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 833 S WESTERN AVE #2
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90005-3376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-384-1001
-----------------------------------------------------
Fax | 213-384-4527
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHELLE H KIM
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 213-248-1001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 12591T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------