Provider Demographics
NPI:1871546341
Name:AGOURA-WEST VALLEY OPTOMETRIC CENTER
Entity type:Organization
Organization Name:AGOURA-WEST VALLEY OPTOMETRIC CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANITA
Authorized Official - Middle Name:SAM
Authorized Official - Last Name:LAI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:818-340-5796
Mailing Address - Street 1:6800 OWENSMOUTH AVE
Mailing Address - Street 2:#400
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-3159
Mailing Address - Country:US
Mailing Address - Phone:818-340-5796
Mailing Address - Fax:818-340-4030
Practice Address - Street 1:6800 OWENSMOUTH AVE
Practice Address - Street 2:#400
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-3159
Practice Address - Country:US
Practice Address - Phone:818-340-5796
Practice Address - Fax:818-340-4030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8019TPL152W00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID
CAU30091Medicare UPIN
CA=========OtherTAX ID
CAWY7857Medicare ID - Type Unspecified
CA0380900002Medicare NSC