1861769135 NPI number — KIM O. NGUYEN O.D., INC.

Table of content: (NPI 1861769135)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861769135 NPI number — KIM O. NGUYEN O.D., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIM O. NGUYEN O.D., INC.
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:
6
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:
1861769135
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25401 ALICIA PKWY
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
LAGUNA HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92653-4958
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-951-8001
Provider Business Mailing Address Fax Number:
959-951-1552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25401 ALICIA PKWY
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
LAGUNA HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92653-4958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-951-8001
Provider Business Practice Location Address Fax Number:
959-951-1552
Provider Enumeration Date:
11/30/2011

Additional Information

Authorized Official

Authorized Official Last Name:
NGUYEN
Authorized Official First Name:
KIM
Authorized Official Middle Name:
OANH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
949-951-8001

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT11972 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CB228572 . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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