Provider Demographics
NPI:1154746345
Name:JIMMY K. SO, OD, INC.
Entity type:Organization
Organization Name:JIMMY K. SO, OD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:K
Authorized Official - Last Name:SO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-982-9366
Mailing Address - Street 1:1261 W FOOTHILL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-8019
Mailing Address - Country:US
Mailing Address - Phone:909-982-9366
Mailing Address - Fax:909-982-2477
Practice Address - Street 1:1261 W FOOTHILL BLVD STE B
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-8019
Practice Address - Country:US
Practice Address - Phone:909-982-9366
Practice Address - Fax:909-982-2477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10554T152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty