1255741468 NPI number — LYNN WATT KURATA, OD FAAO , AN OPTOMETRIC CORPORATION

Table of content: (NPI 1255741468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255741468 NPI number — LYNN WATT KURATA, OD FAAO , AN OPTOMETRIC CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LYNN WATT KURATA, OD FAAO , AN OPTOMETRIC CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255741468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1234 7TH ST
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
SANTA MONICA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90401-1614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-395-5778
Provider Business Mailing Address Fax Number:
310-458-9754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1234 7TH ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
SANTA MONICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90401-1614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-395-5778
Provider Business Practice Location Address Fax Number:
310-458-9754
Provider Enumeration Date:
04/28/2014

Additional Information

Authorized Official

Authorized Official Last Name:
KURATA
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
WATT
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
310-801-7045

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  OPT7676TPG , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X , with the licence number: OPT7676TPG , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PTAN 7394100001 . This is a "NSC DMEPOS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: SD0076763 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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