MEDICARE: QUYEN N. LA O.D., 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	152WC0802X	Corneal and Contact Management Optometrist	12318T	CA
2	152WP0200X	Pediatric Optometrist	12318T	CA
3	152W00000X	Optometrist	12318T	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	WOP12318A	OTHER	CA	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831585348
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUYEN N. LA O.D., INC

Provider Business Mailing Address
First Line	:	77251 WARNER AVE STE. H
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647
Country	:	US
Telephone Number	:	714-596-2258
Fax Number	:

Provider Business Practice Location Address
First Line	:	7251 WARNER AVE STE H
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-5487
Country	:	US
Telephone Number	:	714-596-2258
Fax Number	:

Authorized Official
Title or Position	:	LEAD OPTICIAN
Name	:	KAREN MARIE WALKER
Credential	:
Telephone Number	:	714-596-2258

Provider Enumeration Date	:	04/10/2015
Last Update Date	:	04/10/2015

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