=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689983330
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLENDA B SECOR, OD, FAAO, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2010
-----------------------------------------------------
Last Update Date | 10/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17742 BEACH BLVD 305
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92647-6818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-596-4488
-----------------------------------------------------
Fax | 714-596-5522
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17742 BEACH BLVD 305
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92647-6818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-596-4488
-----------------------------------------------------
Fax | 714-596-5522
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GLENDA SECOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-596-4488
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 6797G
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------