Provider Demographics
NPI:1104371343
Name:PINHKEO SOUTHAPHANH O D INC
Entity type:Organization
Organization Name:PINHKEO SOUTHAPHANH O D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PINHKEO
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHAPHANH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:805-819-0742
Mailing Address - Street 1:415 E OCEAN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-6839
Mailing Address - Country:US
Mailing Address - Phone:805-819-0742
Mailing Address - Fax:805-741-7367
Practice Address - Street 1:415 E OCEAN AVE STE B
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6839
Practice Address - Country:US
Practice Address - Phone:805-819-0742
Practice Address - Fax:805-741-7367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-17
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12359TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1538139381Medicaid
CA1538139381Medicaid