Provider Demographics
NPI:1104261957
Name:MNT OPTOMETRIC, INC.
Entity type:Organization
Organization Name:MNT OPTOMETRIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MURAOKA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-478-0652
Mailing Address - Street 1:2049 BREA MALL
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-5756
Mailing Address - Country:US
Mailing Address - Phone:714-990-9311
Mailing Address - Fax:714-990-2633
Practice Address - Street 1:2049 BREA MALL
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-5756
Practice Address - Country:US
Practice Address - Phone:714-990-9311
Practice Address - Fax:714-990-2633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-07
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB215143Medicare PIN