MEDICARE: TRI NGO 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
1	152W00000X	Optometrist	12745TPA	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OP12745	OTHER	CA	PIN

General Provider Information

NPI Number	:	1902028962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRI NGO O.D.

Provider Business Mailing Address
First Line	:	12053 SYCAMORE LANE
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92843
Country	:	US
Telephone Number	:	714-534-9161
Fax Number	:

Provider Business Practice Location Address
First Line	:	9656 LAS TUNAS DR
Second Line	:
City	:	TEMPLE CITY
State	:	CA
Zip	:	91780-2139
Country	:	US
Telephone Number	:	626-286-1993
Fax Number	:	626-286-1903

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	07/30/2014

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