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General NPI Number Information
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NPI Number | 1811172190
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Entity Type | Organization
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Legal Business Name | GREAT EYES OPTOMETRY, INC
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Dates
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Enumeration Date | 01/04/2008
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Last Update Date | 02/20/2018
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Provider Practice Location Address
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Address Line | 343 S BROADWAY
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City | LOS ANGELES
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State | CA
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Zip | 90013-1207
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Country | US
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Telephone | 213-626-9978
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Fax | 213-628-0500
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Provider Business Mailing Address
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Address Line | 625 LAS DUNAS ST
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City | IMPERIAL
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State | CA
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Zip | 92251-8000
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Country | US
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Telephone | 714-305-7874
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JADE NGOC MY DAVIS
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Credential | O.D.
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Telephone | 213-626-9978
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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 | 11765T
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License Number State | CA
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