=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639728652
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNSHINE OPTOMETRIC CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2019
-----------------------------------------------------
Last Update Date | 09/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10614 LOWER AZUSA RD
-----------------------------------------------------
City | EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91731-1210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-442-6620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10614 LOWER AZUSA RD
-----------------------------------------------------
City | EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91731-1210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-442-6620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. TRAM DANG NGUYEN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 626-337-7148
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------