Provider Demographics
NPI:1235311473
Name:PACIFIC OPTOMETRY GROUP
Entity type:Organization
Organization Name:PACIFIC OPTOMETRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:H
Authorized Official - Last Name:DANG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-775-7045
Mailing Address - Street 1:9600 BOLSA AVE
Mailing Address - Street 2:SUITE C & H
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-5949
Mailing Address - Country:US
Mailing Address - Phone:714-775-7045
Mailing Address - Fax:714-775-7050
Practice Address - Street 1:9600 BOLSA AVE
Practice Address - Street 2:SUITE C & H
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-5949
Practice Address - Country:US
Practice Address - Phone:714-775-7045
Practice Address - Fax:714-775-7050
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PACIFIC OPTOMETRY GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11249T152W00000X, 152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWY148AMedicare PIN