MEDICARE: PACIFIC OPTOMETRY VISION, INC.

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	11932T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6268104535	OTHER	CA	VSP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598923823
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC OPTOMETRY VISION, INC.

Provider Business Mailing Address
First Line	:	2402 S AZUSA AVE
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91792-1512
Country	:	US
Telephone Number	:	626-810-4535
Fax Number	:	626-810-7371

Provider Business Practice Location Address
First Line	:	2402 S AZUSA AVE
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91792-1512
Country	:	US
Telephone Number	:	626-810-4535
Fax Number	:	626-810-7371

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PHONG QUOC NGUYEN
Credential	:	O.D.
Telephone Number	:	626-810-4535

Provider Enumeration Date	:	05/22/2008
Last Update Date	:	11/25/2009

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