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General NPI Number Information
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NPI Number | 1548472921
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Entity Type | Organization
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Legal Business Name | CUSTOM EYES OPTOMETRY, INC.
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Dates
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Enumeration Date | 05/05/2007
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Last Update Date | 03/24/2015
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Provider Practice Location Address
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Address Line | 1835 NEWPORT BLVD SUITE A-111
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City | COSTA MESA
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State | CA
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Zip | 92627-5031
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Country | US
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Telephone | 949-646-4949
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Fax | 949-646-2533
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Provider Business Mailing Address
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Address Line | 1835 NEWPORT BLVD SUITE A-111
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City | COSTA MESA
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State | CA
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Zip | 92627-5031
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Country | US
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Telephone | 949-646-4949
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Fax | 949-646-2533
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL PAUL BOURGOIN
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Credential | O.D.
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Telephone | 949-646-4949
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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 | 9870T
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License Number State | CA
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