=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609016559
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL VISIONCARE OF WEST HOLLYWOOD, INC A PROFESSIONAL OPTOM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2009
-----------------------------------------------------
Last Update Date | 11/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8210 SANTA MONICA BLVD
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90046-5913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-656-9550
-----------------------------------------------------
Fax | 323-650-2490
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8210 SANTA MONICA BLVD
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90046-5913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-656-9550
-----------------------------------------------------
Fax | 323-650-2490
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JIMMY CHENG
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 323-656-9550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 9103T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------