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General NPI Number Information
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NPI Number | 1942881180
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Entity Type | Organization
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Legal Business Name | MINA CHEN OD CORP
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Dates
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Enumeration Date | 04/19/2021
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Last Update Date | 04/19/2021
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Provider Practice Location Address
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Address Line | 157 PETALUMA BLVD N
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City | PETALUMA
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State | CA
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Zip | 94952-2904
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Country | US
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Telephone | 707-285-7475
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Fax | 707-285-7476
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Provider Business Mailing Address
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Address Line | 561 CARLSON AVE APT 332
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City | ROHNERT PARK
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State | CA
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Zip | 94928-2801
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Country | US
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Telephone | 510-709-7294
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST, OWNER
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Name | DR. MINA CHEN
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Credential | OD
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Telephone | 510-709-7294
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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 |
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License Number State |
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