Provider Demographics
NPI:1457537946
Name:RIVIERA VILLAGE OPTOMETRY PC
Entity type:Organization
Organization Name:RIVIERA VILLAGE OPTOMETRY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:OKU
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-540-5545
Mailing Address - Street 1:239 AVENIDA DEL NORTE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-5702
Mailing Address - Country:US
Mailing Address - Phone:310-540-5545
Mailing Address - Fax:310-540-5536
Practice Address - Street 1:239 AVENIDA DEL NORTE
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-5702
Practice Address - Country:US
Practice Address - Phone:310-540-5545
Practice Address - Fax:310-540-5536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6677080001Medicare NSC
CAGD274AMedicare PIN
CADT2971Medicare PIN