=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508571845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIET HUYNH OD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2023
-----------------------------------------------------
Last Update Date | 01/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11133 BALBOA BLVD
-----------------------------------------------------
City | GRANADA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91344-4204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-304-4551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1734 LYDIA CIR
-----------------------------------------------------
City | SIMI VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93065-3512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-304-4551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | KIET LONG HUYNH
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 805-304-4551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------