Provider Demographics
NPI:1609389139
Name:JENNIFER CHE O D A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JENNIFER CHE O D A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:754-229-1918
Mailing Address - Street 1:625 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3107
Mailing Address - Country:US
Mailing Address - Phone:310-833-2495
Mailing Address - Fax:
Practice Address - Street 1:625 W 9TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3107
Practice Address - Country:US
Practice Address - Phone:310-833-2495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-07
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3494144Medicaid