=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942523139
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED LASER CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2010
-----------------------------------------------------
Last Update Date | 03/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 S WINCHESTER BLVD SUITE 250
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95128-2092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-296-0102
-----------------------------------------------------
Fax | 408-296-1795
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 S WINCHESTER BLVD SUITE 250
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95128-2092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-296-0103
-----------------------------------------------------
Fax | 408-296-1795
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR
-----------------------------------------------------
Name | GREGORY HUAN PHAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 408-296-0103
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS0132X
-----------------------------------------------------
Taxonomy Name | Ophthalmologic Surgery Clinic/Center
-----------------------------------------------------
License Number | G77619
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------