Provider Demographics
NPI:1285894469
Name:MUKACHEVA, OLGA
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:
Last Name:MUKACHEVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5741 CARLTON WAY
Mailing Address - Street 2:#210
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-6754
Mailing Address - Country:US
Mailing Address - Phone:323-317-2093
Mailing Address - Fax:
Practice Address - Street 1:7626 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-6409
Practice Address - Country:US
Practice Address - Phone:323-317-2093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7338156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician