Provider Demographics
NPI:1194998443
Name:SUPERVISION OPTOMETRY INC
Entity type:Organization
Organization Name:SUPERVISION OPTOMETRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHIEH JU
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-962-2839
Mailing Address - Street 1:1200 S SUNSET AVE
Mailing Address - Street 2:SUITE #1
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3903
Mailing Address - Country:US
Mailing Address - Phone:626-962-2839
Mailing Address - Fax:626-962-1819
Practice Address - Street 1:1200 S SUNSET AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3903
Practice Address - Country:US
Practice Address - Phone:626-962-2839
Practice Address - Fax:626-962-1819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA13182T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0131820Medicaid
CAV10759Medicare UPIN
CASD0131820Medicaid