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NPI Code Detail

MEDICARE: EMILY K SO O.D.

MEDICARE: EMILY K SO O.D.
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
1152W00000XOptometristTLG13859CA

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1EN061HOTHERCAMEDICARE PTAN

General Provider Information

NPI Number : 1619295334
Entity Type Code : Individual
Provider Name (Legal Business Name) : EMILY K SO O.D.
Provider Business Mailing Address
First Line : 301 W. HUNTINGTON DR.
Second Line : SUITE #107
City : ARCADIA
State : CA
Zip : 91007-3400
Country : US
Telephone Number : 626-574-0022
Fax Number : 626-574-0040
Provider Business Practice Location Address
First Line : 17833 COLIMA RD
Second Line :
City : ROWLAND HEIGHTS
State : CA
Zip : 91748-1729
Country : US
Telephone Number : 626-964-7764
Fax Number : 626-913-2910
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/05/2010
Last Update Date : 03/12/2012

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