Provider Demographics
NPI:1538403274
Name:NUEVA VISION OPTICAL
Entity type:Organization
Organization Name:NUEVA VISION OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:BUSTAMANTE
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:310-604-3851
Mailing Address - Street 1:3100 E IMPERIAL HWY
Mailing Address - Street 2:SUITE # 1109
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3202
Mailing Address - Country:US
Mailing Address - Phone:310-604-3851
Mailing Address - Fax:310-878-0301
Practice Address - Street 1:3100 E IMPERIAL HWY
Practice Address - Street 2:SUITE # 1109
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3202
Practice Address - Country:US
Practice Address - Phone:310-604-3851
Practice Address - Fax:310-878-0301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2945305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization