Provider Demographics
NPI:1588771380
Name:JUSTIN T ABO O D A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JUSTIN T ABO O D A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ABO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-899-0026
Mailing Address - Street 1:12759 FOOTHILL BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-9336
Mailing Address - Country:US
Mailing Address - Phone:909-899-0026
Mailing Address - Fax:909-899-6381
Practice Address - Street 1:12759 FOOTHILL BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-9336
Practice Address - Country:US
Practice Address - Phone:909-899-0026
Practice Address - Fax:909-899-6381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11100T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty