Provider Demographics
NPI:1154514370
Name:SOUTH GATE OPTOMETRY INC
Entity type:Organization
Organization Name:SOUTH GATE OPTOMETRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PENNINO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:323-566-6183
Mailing Address - Street 1:3329 TWEEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-4324
Mailing Address - Country:US
Mailing Address - Phone:323-566-6183
Mailing Address - Fax:
Practice Address - Street 1:3329 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-4324
Practice Address - Country:US
Practice Address - Phone:323-566-6183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9996T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0099960Medicaid
CAW21922Medicare PIN