Provider Demographics
NPI:1063057941
Name:CHHIN, KACLICA (RSLD)
Entity type:Individual
Prefix:MS
First Name:KACLICA
Middle Name:
Last Name:CHHIN
Suffix:
Gender:F
Credentials:RSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11605 N LAMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753-2658
Mailing Address - Country:US
Mailing Address - Phone:737-222-6996
Mailing Address - Fax:512-522-8836
Practice Address - Street 1:15520 GOLDENWEST ST # 8885
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-2752
Practice Address - Country:US
Practice Address - Phone:657-666-7159
Practice Address - Fax:714-379-3304
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41370156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician