Provider Demographics
NPI:1215127550
Name:LORETTA M LI OD
Entity type:Organization
Organization Name:LORETTA M LI OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:MUI WAN
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-892-3636
Mailing Address - Street 1:9022 BOLSA AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683
Mailing Address - Country:US
Mailing Address - Phone:714-892-3636
Mailing Address - Fax:714-892-6273
Practice Address - Street 1:9022 BOLSA AVE
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683
Practice Address - Country:US
Practice Address - Phone:714-892-3636
Practice Address - Fax:714-892-6273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75147152W00000X
CA124597152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0075140Medicaid
OP7514Medicare PIN
CASD0075140Medicaid