MEDICARE: IMPERIAL VALLEY OPTOMETRIC CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

General Provider Information

NPI Number	:	1518858208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPERIAL VALLEY OPTOMETRIC CORPORATION

Provider Business Mailing Address
First Line	:	10549 SCRIPPS POWAY PKWY STE G
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92131-3963
Country	:	US
Telephone Number	:	858-530-2800
Fax Number	:

Provider Business Practice Location Address
First Line	:	10549 SCRIPPS POWAY PKWY STE G
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92131-3963
Country	:	US
Telephone Number	:	858-530-2800
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	HENRY LIN
Credential	:
Telephone Number	:	619-295-2900

Provider Enumeration Date	:	07/11/2025
Last Update Date	:	07/11/2025

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